Alcohol Dependence and Mortality: Implications for Treatment — Authors' Reply

We would like to thank Cook for her commentary (Cook, 2015Cook S. Alcohol dependence and mortality: implications for treatment.EBioMedicine. 2015; 2: 1281-1282Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar) in this issue of EBioMedicine, which deals with not only our findings (Laramee et al., 2015Laramee P. Leonard S. Buchanan-Hughes A. et al.Risk of all-cause mortality in alcohol-dependent individuals: a systematic literature review and meta-analysis.EBioMedicine. 2015; 2: 1394-1404Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar) but also the implications for treatment and setting up a treatment system. While generally agreeing with Cook, we differ in one aspect that alcohol use disorders in general and alcohol dependence specifically are not recognized. A recent large-scale study in 6 European countries showed that GPs did recognize alcohol dependence, in fact, they identified more severe cases than standardized instruments such as the CIDI (Rehm et al., 2015aRehm J. Allamani A. Elekes Z. et al.General practitioners recognizing alcohol dependence: a large cross-sectional study in six European countries.Ann. Fam. Med. 2015; 13: 28-32Crossref PubMed Scopus (74) Google Scholar, Mitchell et al., 2012Mitchell A.J. Meader N. Bird V. Rizzo M. Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis.Br. J. Psychiatry. 2012; 201: 93-100Crossref PubMed Scopus (85) Google Scholar). This implies that recognition is not the main reason why alcohol dependence is having a low treatment rate. One problem here seems to be that most countries see no role for treatment at the primary health care level; the leading paradigm recommends screening, brief advice/interventions for alcohol problems and referral to specialized treatment for alcohol dependence (Babor et al., 2007Babor T.F. McRee B.G. Kassebaum P.A. Grimaldi P.L. 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: 7-30Crossref PubMed Scopus (690) Google Scholar; http://pathways.nice.org.uk/pathways/alcohol-usedisorders/brief-interventions-for-alcohol-use-disorders). In other words, GPs are restricted to non-treatment roles, i.e., roles outside the core professional identity. Moreover, referral is not too popular with patients, who believe that they can cope with the problem themselves (Probst et al., 2015Probst C. Manthey J. Martinez A. Rehm J. Alcohol use disorder severity and reported reasons not to seek treatment: a cross-sectional in European primary care practices.Subst. Abuse Treat. Prev. Policy. 2015; 10: 32Crossref PubMed Google Scholar), and because of stigmatization tend to postpone interventions until they are unavoidable (Rehm et al., 2015bRehm J. Manthey J. Struzzo P. Gual A. Wojnar M. Who receives treatment for alcohol use disorders in the European Union? A cross-sectional representative study in primary and specialized health care.Euro Psych. 2015; (in press)Crossref Scopus (39) Google Scholar). Moreover, a recent review did not see much evidence for this kind of referral (Glass et al., 2015Glass J.E. Hamilton A.M. Powell B.J. Perron B.E. Brown R.T. Ilgen M.A. Specialty substance use disorder services following brief alcohol intervention: a meta-analysis of randomized controlled trials.Addiction. 2015; 110 (in press)Crossref Scopus (99) Google Scholar). In conclusion, only if the role of primary health care is redefined, including but not limited to remuneration of treatment, there seems to be reasonable hope to reduce the treatment gap. It has been proposed that GPs should address alcohol use and alcohol dependence analogously to blood pressure and hypertension (Nutt and Rehm, 2014Nutt D.J. Rehm J. Doing it by numbers: a simple approach to reducing the harms of alcohol.J. Psychopharmacol. 2014; 28: 3-7Crossref PubMed Scopus (50) Google Scholar), and this strategy may prove to be the way forward. PL was an employee of Lundbeck SAS at the time this study was conducted; SL and AB-H are employees of Costello Medical Consulting, which was contracted by Lundbeck SAS to support this study; SW received personal fees from Costello Medical Consulting during the conduct of this study; J-BD received personal fees from Lundbeck SAS during the conduct of this study; JR has received grants, personal fees and non-financial support from Lundbeck SAS, outside the submitted work. Alcohol Dependence and Mortality: Implications for TreatmentAlcohol use disorders are the most common mental disorder worldwide with an estimated 3.6% prevalence among adults aged 15–65 (Rehm et al., 2009). They are associated with significant morbidity as well as negative social consequences for both the sufferer and those around them. Full-Text PDF Open AccessRisk of All-Cause Mortality in Alcohol-Dependent Individuals: A Systematic Literature Review and Meta-AnalysisAD was found to significantly increase an individual's risk of all-cause mortality. While abstinence in alcohol-dependent subjects led to greater mortality reduction than non-abstinence, this study suggests that alcohol-dependent subjects can significantly reduce their mortality risk by reducing alcohol consumption. Full-Text PDF Open Access

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