Docs Miss Alcohol Abuse -- Almost Always

From the WebMD Archives

May 10, 2000 (Washington) -- Primary care physicians miss telltale signs that would suggest a diagnosis of alcohol abuse, according to a new survey of doctors and their patients. The findings show that this lost opportunity occurs an incredible 94% of the time.

"This is a screaming alarm for doctors and patients. It's more than a wake-up call. ... Substance abuse is an elephant in the examining room," Joseph Califano, president of the National Center on Addiction and Substance Abuse (CASA) at Columbia University, tells WebMD. Califano's organization (CASA) released the study at a news conference here Wednesday.

The results also revealed that 41% of pediatricians failed to diagnose illegal drug use in teen-agers even when presented with obvious signs of substance abuse. All doctors involved in the analysis were given the opportunity to suggest substance abuse among five possible diagnoses they were asked to make.

Among the survey's other key findings:

  • Nearly 20% of physicians feel they are "very prepared" to diagnose alcoholism, and just 16.9% say they're confident about diagnosing illegal drug use.
  • More than half of patients say the primary care physician did nothing about their addiction.
  • Almost 11% of the patients polled say that their physician was aware of an addiction but did nothing.
  • Most physicians believe there are effective treatments for chronic illnesses such as high blood pressure, but few physicians thought addiction therapies work well.

CASA surveyed 648 doctors around the country, including internists, ob-gyns, and pediatricians, and 510 patients.

Describing substance abuse and addiction as America's No. 1 disease, Califano, a former secretary of the Department of Health, Education and Welfare, says medical schools and other education programs for physicians need to provide more training on how to spot and deal with substance abuse.

Doctors may simply be embarrassed to ask the key questions, says Califano. "They don't want to anger their patients. ... They think patients will lie about this," says Califano.

The report also recommends that licensing boards require physicians to have more knowledge of abuse and addiction issues and that primary care physicians get adequate reimbursement for dealing with these problems.

That problem would be at least partly relieved by the passage of so-called parity legislation that would require insurance companies to cover addictions like other diseases, says the report. However, since most doctors are involved in cost-cutting managed care plans, there still may not be enough time to figure out that a patient is suffering from a substance abuse issue.

"Particularly, if they [primary care doctors] haven't been taught that there are places to refer, that there are treatments that do work ... if it seems to them as if this is a hopeless thing anyway, why bring it up?" asks June Osborn, MD, president of the Josiah Macy Jr., Foundation, which funded the study.

The study could just as easily have come to the same conclusion about all physicians, not just those in primary care, according to Sam Cullison, MD, a Seattle family physician who's also a specialist in addiction medicine. He agrees that more training in addiction and substance abuse is desirable, but he tells WebMD the study's recommendation that doctors be held liable for missing such a diagnosis a "crazy" attempt at punishing physicians.

Cullison, a clinical associate professor of family medicine in a residency program affiliated with the University of Washington School of Medicine, says that if a patient came in for a sore throat, Cullison wouldn't necessarily ask questions about alcohol or drugs unless there were obvious signs -- such as alcohol on one's breath or a deviated septum from cocaine use. However, substance abuse and addiction questions would come up in detail on an annual physical.