Core Resource on Alcohol

Only about 7% of adults who had alcohol use disorder (AUD) in the past year accessed any kind of treatment; thus, a sizeable number of people who could benefit are not receiving treatment.¹

Once you determine that a patient has AUD, the next step for patient care depends in part on the level of AUD severity. (See Core article on screening and assessment.) Some patients may be able to receive treatment in primary care via brief interventions and FDA-approved AUD medications, whereas those with more severe AUD or with mental health comorbidities will likely need a referral to specialty behavioral and pharmacologic care.² (See Core articles on brief intervention, treatment, and mental health issues.)

Connecting patients to specialty treatment for AUD involves typical referral challenges such as identifying the patients in need, finding local specialists with availability, and exchanging information with the specialists.^3,4 Further, referral for AUD is compounded by barriers related to perceptions about AUD treatment and the logistics of finding quality specialty care that the patient can afford.^5,6 Here, we describe some of these barriers and possible ways to reduce them.

What perceptions may set up barriers to AUD referral?

Both clinicians and patients may live in a context of intense social stigma around AUD. (See Core article on stigma.) Thus, each may have erroneous beliefs about specialist referral,^6,7 including:

• Mistaken beliefs that treatment for AUD is ineffective, that motivated patients should be able to stop on their own, or that prior relapse predicts future nonresponse to treatment.
• Misguided assumptions that patients must “hit rock bottom” before they will accept treatment or that referral is appropriate only for patients who desire complete abstinence from alcohol.
• Judging incorrectly that a patient’s problem isn’t serious enough to warrant specialty referral, or holding stereotypes that treatment is only for a certain, other kind of person. These barriers may be particularly prominent when alcohol problems are identified by screening rather than raised by the patient.

These misperceptions can be magnified by a common, dated, and narrow view of alcohol treatment options, including:

• Misunderstandings that treatment is limited to options such as inpatient rehab and 12-step programs, which benefit many patients but will not be a good fit for all.
• Lack of knowledge about newer AUD medications (acamprosate and naltrexone) that patients may find more appealing than the older medication (disulfiram), which makes people sick when they drink alcohol.⁸

To learn about the current broad range of evidence-backed treatment options, available at different levels of intensity, see the Core article on treatment and the NIAAA Alcohol Treatment Navigator. 

What logistical barriers complicate referral for AUD?

Historically, addiction treatment in the U.S. has been separated from the rest of healthcare, addressed in physically and organizationally distinct institutions, often without medical providers.⁹ Although policy changes have encouraged integration,¹⁰ persistent silos may create barriers to making referrals for AUD. These barriers are compounded by privacy protections specific to addiction treatment that can hamper information exchange across institutions.^9,11 In addition, financial hurdles have been reduced but not eliminated,¹² despite legal changes requiring insurance payment parity for alcohol and other substance use disorders.¹⁰

Moreover, it’s not always easy to find evidence-based care for AUD. In much of the U.S., specialty treatment for addiction is limited in availability and variable in quality.^12–15 Licensing requirements for addiction treatment vary by state. Education and training of providers may be limited and standards may be inadequate to ensure uptake of evidence-based practices.¹⁴ The next section describes an online tool NIAAA designed to facilitate the search for high quality, evidence-based alcohol treatment.

How can you best locate quality, evidence-based care for patients with AUD?

Thousands of programs and providers in the U.S. offer evidence-based alcohol treatment, and NIAAA created the Alcohol Treatment Navigator to help people find them. Unlike many other resources you and your patients may find online, the Navigator has no commercial sponsors. The Navigator notes that the most expensive treatment is not always the best; offers expert advice on how to recognize quality, evidence-backed care; and provides links to search for local specialists. It emphasizes the diversity of treatment options, which includes not only traditional, higher-intensity inpatient or residential programs, but also individual therapists and specialty physicians who can offer lower intensity (and potentially more affordable) outpatient and telehealth care. The Navigator’s portal for healthcare professionals shows how to expand your referral lists and share the Navigator with patients.

What can you and your practice do to facilitate specialist referrals for AUD?

To address problematic patterns of alcohol use, many healthcare professionals and systems provide screening, brief intervention, and referral to treatment (SBIRT).¹⁶ (See Core articles on screening and brief intervention.) National survey data suggests that among people with AUD in the past year, those who received alcohol SBIRT in a past-year medical visit were more likely to attend specialty treatment than those whose medical visits did not include SBIRT.¹⁷

The strategies described below may facilitate referrals. First, you can identify patients who might benefit from referral by using structured tools such as a brief alcohol screener and an AUD symptom checklist. (See Core article on screening and assessment.) Then, in discussing referral, it may be helpful to:

• Proactively acknowledge and reduce stigma. Help patients understand that AUD is a common, treatable health condition that can happen to anyone. Normalize AUD treatment as similar to specialty care for other chronic medical conditions.¹⁸ (See Core article on stigma.)
• Inform your patients that AUD treatment is effective and that a range of medications and behavioral health treatments can help them cut down or quit drinking or achieve abstinence.¹⁹
• Consider patient preferences and note potentially appealing treatment options, such as flexible outpatient or telehealth care that helps preserve patient privacy and routines, AUD medications, and, for some, stepped treatment goals that may start with significantly reducing the amount and frequency of alcohol consumed. (See Core articles on brief intervention and treatment and the Navigator.)
• Consider patients’ ability to pay for treatment when making referrals. Become familiar with options for patients with limited financial means (see Resources).
• Note that the most expensive treatment is not always the best, as mentioned previously, whereas getting individualized, evidence-based care matters most. (See Core article on treatment.)

At the health system level, steps to support referral may aim for integration of addiction treatment, including basic coordination of services, co-location of services, or even fully integrated teams. As a first step in coordination, affiliation or service agreements can standardize referrals and facilitate information exchange across institutions in ways consistent with privacy regulations.²⁰ Regarding co-location of services, recent studies with hospital patients have demonstrated improved referral completion when SBIRT was performed on-site by specialists who were on staff or from a local substance use treatment center.^21,22 Some U.S. grant-funded SBIRT programs have moved towards fully integrated teams using specialized staff to perform SBIRT.²³

How do you refer patients to mutual support groups?

Although mutual support groups are not professionally-led treatments, you can offer referral for patients who are interested in this approach by providing lists of groups that meet online or in-person (see resources below). You can enhance the referral process by describing different groups and recommending ones in which other patients have done well.²⁴ When following up, you might ask about attendance, impressions, and whether the patient has found a sponsor.

Although Alcoholics Anonymous (AA) is the largest mutual support group, it’s important to be familiar with alternatives. Some groups such as Secular AA or SMART Recovery are structured without spiritual or 12-step components, some are for women only, and some focus on harm reduction rather than abstinence. Even within organizations, individual groups vary widely, so encourage patients to try multiple options as needed to find a good fit.

Research has demonstrated that patients may get more out of mutual support groups when they receive twelve-step facilitation, a structured clinical support approach.^25,26 Even without special training in this support model, you can help patients make the most of their participation in mutual support groups by explaining concepts, locating meetings, and promoting attendance and engagement.

When considering referrals to specialists or mutual support groups, keep in mind that no single treatment approach will be appealing or effective for all your patients with AUD. Some may benefit from a blend of approaches. See the Core article on treatment for an overview of all the evidence-based options, which can be combined and tailored to each patient’s needs.

What can you do when a patient declines referral or doesn’t follow through?

Despite your efforts, many patients may not accept or follow through on a referral, at least initially. In these cases, extended or repeated brief interventions can focus on the patient’s readiness for and confidence in making a change. (See Core article on brief interventions.) These interventions may occur in primary care settings or after specialty or emergency room visits related to alcohol use. They may involve the initial treating clinician or specially trained staff and may be done in person or by phone.^7,23 

If you see patients for ongoing care for other conditions, you can use the rapport developed through those visits to break down stigma and encourage acceptance of alcohol treatment. Conversely, if the original interaction was expected to be a single visit, arranging telehealth or in-person follow-up regarding alcohol can convey genuine concern.

For patients who choose not to pursue specialty treatment, care management, including medications, can be offered in primary care, as noted previously. Self-management with web-based resources^27,28 or joining a mutual support group are additional non-specialist alternatives (see Resources). Note that the natural history of AUD is varied. Although some people recover without formal treatment,^29–31 research shows that treatment improves rates of abstinence and nonheavy drinking among people with moderate to severe AUD.³² (See Core article on recovery.)

In closing, referral may be a process rather than a one-time event. Simple persistence and optimism may be required. If a conversation with a patient does not lead to a referral, nonetheless it may plant a seed, increasing the potential for treatment seeking down the line. It may help to advise patients that regardless of whether they accept treatment, they should not wait for a crisis or to “hit rock bottom” to reduce their alcohol consumption. Making a change sooner rather than later is likely to be more successful and can mitigate harm to individuals and their families.