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The Healthcare Professional's

Core Resource on Alcohol

Knowledge. Impacts. Strategies.

Make Referrals: Connect Patients to Alcohol Treatment That Meets Their Needs

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    Step 2 - Complete the Brief Continuing Education Post-Test

    Takeaways

    • For some patients, alcohol treatment referral may not be a single event but instead part of an ongoing process of engagement.
    • You can help patients surmount barriers to following through on a treatment referral by countering the effects of stigma, conveying that treatment can be effective, and offering a range of choices for care.
    • Today’s treatment options may be more acceptable to many patients, including FDA-approved medications for alcohol use disorder that can be offered in primary care, along with flexible, lower-intensity outpatient and telehealth options for specialty care.
    • The NIAAA Alcohol Treatment Navigator can help healthcare professionals and patients to find specialty programs and individual providers that offer evidence-based care tailored to each individual’s needs.

    Only about 7.8% 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 those 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

    Additionally, people with severe, untreated AUD may not seek treatment because they perceive they do not have an alcohol-related problem, they do not want to stop drinking, or they prefer to handle drinking problems on their own.9

    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.10 Policy changes have encouraged integration of behavioral health records with other medical records, including a 2024 federal regulation that makes it easier to share substance use disorder records once a patient gives a single written consent.11,12 However, silos may persist and hinder referrals for AUD. In addition, financial hurdles have been reduced but not eliminated, 13 despite legal changes requiring insurance payment parity for alcohol and other substance use disorders.11,12

    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.13–16 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.15 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).17 (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.18

    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. 19 (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.20
    • 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.21 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.22,23 Some U.S. grant-funded programs have moved towards fully integrated teams using specialized staff to perform SBIRT.24

    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.25 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.26,27 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.7,24 

    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 resources28,29 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,30–32 research shows that treatment improves rates of abstinence and nonheavy drinking among people with moderate to severe AUD.33 (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.

    Resources

    Referral Resources

    Mutual Support Groups

    More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care.

    References

    1. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Alcohol Treatment in the United States. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Accessed December 19, 2024. /alcohols-effects-health/alcohol-topics-z/alcohol-facts-and-statistics/alcohol-treatment-united-states
    2. Saitz R. Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking. Drug Alcohol Rev. 2010;29(6):631-640. doi:10.1111/j.1465-3362.2010.00217.x
    3. Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q. 2011;89(1):39-68. doi:10.1111/j.1468-0009.2011.00619.x
    4. Greenwood-Lee J, Jewett L, Woodhouse L, Marshall DA. A categorisation of problems and solutions to improve patient referrals from primary to specialty care. BMC Health Serv Res. 2018;18(1):986. doi:10.1186/s12913-018-3745-y
    5. Saitz R. “SBIRT” is the answer? Probably not. Addiction. 2015;110(9):1416-1417. doi:10.1111/add.12986
    6. Glass JE, Andréasson S, Bradley KA, et al. Rethinking alcohol interventions in health care: a thematic meeting of the International Network on Brief Interventions for Alcohol & Other Drugs (INEBRIA). Addict Sci Clin Pract. 2017;12(1):14. doi:10.1186/s13722-017-0079-8
    7. Cucciare MA, Coleman EA, Timko C. A conceptual model to facilitate transitions from primary care to specialty substance use disorder care: a review of the literature. Prim Health Care Res Dev. 2015;16(5):492-505. doi:10.1017/S1463423614000164
    8. Wallhed Finn S, Bakshi AS, Andréasson S. Alcohol consumption, dependence, and treatment barriers: perceptions among nontreatment seekers with alcohol dependence. Subst Use Misuse. 2014;49(6):762-769. doi:10.3109/10826084.2014.891616
    9. Hutchison M, Szafranski S, Titus C, et al. An assessment of beliefs about mental health care among community-based adults with severe, untreated alcohol use disorder. Alcohol Alcohol. 2024;59(4):agae037. doi:10.1093/alcalc/agae037
    10. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. HSS; 2016. Accessed May 23, 2020. https://www.ncbi.nlm.nih.gov/books/NBK424848/
    11. Buck JA. The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Aff (Millwood). 2011;30(8):1402-1410. doi:10.1377/hlthaff.2011.0480
    12. Rights (OCR) O for C. Fact Sheet 42 CFR Part 2 Final Rule. February 7, 2024. Accessed January 13, 2025. https://www.hhs.gov/hipaa/for-professionals/regulatory-initiatives/fact-sheet-42-cfr-part-2-final-rule/index.html
    13. Geissler KH, Evans EA. Changes in Medicaid Acceptance by Substance Abuse Treatment Facilities After Implementation of Federal Parity. Med Care. 2020;58(2):101-107. doi:10.1097/MLR.0000000000001242
    14. Carroll KM. Dissemination of evidence-based practices: how far we’ve come, and how much further we’ve got to go. Addiction. 2012;107(6):1031-1033. doi:10.1111/j.1360-0443.2011.03755.x
    15. Addiction Medicine: Closing the Gap Between Science and Practice. National Center on Addiction and Substance Abuse at Columbia University; 2012. https://drugfree.org/reports/addiction-medicine-closing-the-gap-between-science-and-practice/
    16. McLellan AT, Meyers K. Contemporary addiction treatment: a review of systems problems for adults and adolescents. Biol Psychiatry. 2004;56(10):764-770. doi:10.1016/j.biopsych.2004.06.018
    17. Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse. Subst Abus. 2007;28(3):7-30. doi:10.1300/J465v28n03_03
    18. Bandara SN, Samples H, Crum RM, Saloner B. Is screening and intervention associated with treatment receipt among individuals with alcohol use disorder? Evidence from a national survey. J Subst Abuse Treat. 2018;92:85-90. doi:10.1016/j.jsat.2018.06.009
    19. McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug Dependence, a Chronic Medical IllnessImplications for Treatment, Insurance, and Outcomes Evaluation. JAMA. 2000;284(13):1689-1695. doi:10.1001/jama.284.13.1689
    20. Witkiewitz K, Litten RZ, Leggio L. Advances in the science and treatment of alcohol use disorder. Sci Adv. 2019;5(9):eaax4043. doi:10.1126/sciadv.aax4043
    21. Massachusetts Department of Public Health. SBIRT: A Step by Step Guide. Published online 2012. https://massclearinghouse.ehs.state.ma.us/PROG-BSAS-SBIRT/SA3522.html
    22. Bruguera P, Barrio P, Oliveras C, et al. Effectiveness of a Specialized Brief Intervention for At-risk Drinkers in an Emergency Department: Short-term Results of a Randomized Controlled Trial. Acad Emerg Med. 2018;25(5):517-525. doi:10.1111/acem.13384
    23. Schwarz AS, Nielsen B, Søgaard J, Søgaard Nielsen A. Making a bridge between general hospital and specialised community-based treatment for alcohol use disorder-A pragmatic randomised controlled trial. Drug Alcohol Depend. 2019;196:51-56. doi:10.1016/j.drugalcdep.2018.12.017
    24. Vendetti J, Gmyrek A, Damon D, Singh M, McRee B, Del Boca F. Screening, brief intervention and referral to treatment (SBIRT): implementation barriers, facilitators and model migration. Addiction. 2017;112 Suppl 2:23-33. doi:10.1111/add.13652
    25. Timko C, Debenedetti A, Billow R. Intensive referral to 12-Step self-help groups and 6-month substance use disorder outcomes. Addiction. 2006;101(5):678-688. doi:10.1111/j.1360-0443.2006.01391.x
    26. Kelly JF, Humphreys K, Ferri M. Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database of Systematic Reviews. 2020;(3). doi:10.1002/14651858.CD012880.pub2
    27. McCrady BS. Recent Research into Twelve-Step Programs. In: Fiellin DA, Miller SC, Saitz R, Rosenthal RN, eds. The ASAM Principles of Addiction Medicine. Sixth edition. Wolters Kluwer Health/Lippincott Williams & Wilkins; 2019.
    28. Kiluk BD, Devore KA, Buck MB, et al. Randomized Trial of Computerized Cognitive Behavioral Therapy for Alcohol Use Disorders: Efficacy as a Virtual Stand-Alone and Treatment Add-On Compared with Standard Outpatient Treatment. Alcohol Clin Exp Res. 2016;40(9):1991-2000. doi:10.1111/acer.13162
    29. Hester RK, Squires DD, Delaney HD. The Drinker’s Check-up: 12-month outcomes of a controlled clinical trial of a stand-alone software program for problem drinkers. J Subst Abuse Treat. 2005;28(2):159-169. doi:10.1016/j.jsat.2004.12.002
    30. Dawson DA, Grant BF, Stinson FS, Chou PS, Huang B, Ruan WJ. Recovery from DSM-IV alcohol dependence: United States, 2001-2002. Addiction. 2005;100(3):281-292. doi:10.1111/j.1360-0443.2004.00964.x
    31. Fan AZ, Chou SP, Zhang H, Jung J, Grant BF. Prevalence and Correlates of Past-Year Recovery From DSM-5 Alcohol Use Disorder: Results From National Epidemiologic Survey on Alcohol and Related Conditions-III. Alcohol Clin Exp Res. 2019;43(11):2406-2420. doi:10.1111/acer.14192
    32. Tucker JA, Chandler SD, Witkiewitz K. Epidemiology of Recovery From Alcohol Use Disorder. Alcohol Res. 2020;40(3):02. doi:10.35946/arcr.v40.3.02
    33. Weisner C, Matzger H, Kaskutas LA. How important is treatment? One-year outcomes of treated and untreated alcohol-dependent individuals. Addiction. 2003;98(7):901-911. doi:10.1046/j.1360-0443.2003.00438.x
    Complete the Brief Continuing Education Post-Test

    We invite healthcare professionals to complete a post-test to earn FREE continuing education credit (CME/CE or ABIM MOC). This continuing education opportunity is jointly provided by the Postgraduate Institute for Medicine and NIAAA. Learn more about credit designations here.

    There are two credit paths—please choose the one that aligns with your profession.

    These professionals can earn 0.75 credits for reading this single article:

    • Physicians (and others who can earn AMA credit)
    • Physician Assistants
    • Nurses
    • Pharmacists

    To earn AMA, AAPA, ANCC, ACPE, or ABIM MOC credit, review this article, then use the link below to log into or create a CME University account. Answer 3 out of 4 questions correctly on the post-test to earn 0.75 credits.

    These professionals can earn 1.5 credits for reading a pair of articles as indicated below:

    • Licensed Psychologists (and others who can earn APA credit)
    • Social Workers

    To earn APA or ASWB credit, review this article and Topic 14—Promote Practice Change: Take Manageable Steps Toward Better Care, then use the link below to log into or create a CME University account. Answer 7 out of 10 questions correctly on the combined post-test to earn 1.5 credits.

    Released on 5/9/2025
    Expires on 5/10/2026

    Learning Objectives

    After completing this activity, the participant should be better able to:

    • Identify barriers to making effective referrals to treatment for AUD.
    • Discuss various treatment options to which patients with AUD may be referred.
    • Develop practice processes that will address the steps of screening to referral.

    Contributors

    Make Referrals: Connect Patients to Alcohol Treatment That Meets Their Needs

    Contributors to this article for the NIAAA Core Resource on Alcohol include the writer for the full article, content contributors to subsections, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff. All those listed below contributed to the original Core Resource launched in 2022. Those marked with an asterisk (*) also contributed to the recertification update launched in 2025.

    External Writer

    *Douglas Berger MD, MLitt
    Staff Physician, VA Puget Sound;
    Associate Professor of Medicine,
    University of Washington, Seattle, WA

    NIAAA Content Contributors

    *Raye Z. Litten, PhD
    Editor and Content Advisor for
    The Core Resource on Alcohol;
    Former Director,
    Division of Treatment and Recovery, NIAAA

    *Laura E. Kwako, PhD
    Editor and Content Advisor for
    The Core Resource on Alcohol;
    Chief, Treatment, Health Services, and Recovery Branch;
    Credentialed Clinician (Psychologist),
    Division of Treatment and Recovery, NIAAA

    *Maureen B. Gardner
    Project Manager and Technical Writer/Editor for
    The Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    External Reviewers

    *Douglas Berger MD, MLitt
    Staff Physician, VA Puget Sound;
    Associate Professor of Medicine,
    University of Washington, Seattle, WA

    *Kenneth R. Conner, PsyD, MPH
    Professor, Emergency Medicine and Psychiatry,
    University of Rochester Medical Center, Rochester, NY

    *Anne C. Fernandez, PhD
    Assistant Professor of Psychiatry,
    University of Michigan, Ann Arbor, MI 

    *Joseph Edwin Glass, PhD, MSW
    Associate Investigator, Kaiser Permanente Washington
    Health Research Institute, Seattle, WA

    NIAAA Reviewers

    *George F. Koob, PhD
    Director, NIAAA

    *Patricia Powell, PhD
    Deputy Director, NIAAA

    Falk W. Lohoff, MD
    Lasker Clinical Research Scholar;
    Chief, Section on Clinical Genomics and
    Experimental Therapeutics, NIAAA

    *Lorenzo Leggio, MD, PhD
    Clinical Director and Deputy Scientific Director, NIDA;
    Branch Chief and Senior Investigator, NIDA/NIAAA,
    NIH Intramural Research Program, Baltimore, MD

    Aaron White, PhD
    Senior Scientific Advisor to the NIAAA Director, NIAAA

    Editorial Team

    NIAAA

    *Raye Z. Litten, PhD
    Editor and Content Advisor for
    The Core Resource on Alcohol;
    Former Director,
    Division of Treatment and Recovery, NIAAA

    *Laura E. Kwako, PhD
    Editor and Content Advisor for
    The Core Resource on Alcohol;
    Chief, Treatment, Health Services, and Recovery Branch;
    Credentialed Clinician (Psychologist),
    Division of Treatment and Recovery, NIAAA

    *Maureen B. Gardner
    Project Manager and Technical Writer/Editor for
    The Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    Contractor Support

    *Elyssa Warner, PhD
    Technical Editor, Ripple Effect

    *Daria Turner, MPH
    Reference and Resource Analyst, Ripple Effect

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