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Improving prescriber and nonprescriber collaboration in the treatment of alcohol dependence.

Treatment of alcohol dependence and other addictions has increasingly become "medicalized" because of a greater understanding of brain neurophysiology and the accompanying rise in the number of effective medications for these disorders. There is also an increasing demand for treatment accountability and evidence-based treatment driven in part by patients, who have more information available to them through the Internet and other sources, as well as by managed care, which attempts to make healthcare delivery decisions based on proven treatments. These trends are spurring treatment providers to examine the demand for and use of medications--those with efficacy that has been demonstrated in clinical trials--and require increased collaboration between medication prescribers (usually physicians) and nonprescribing addiction specialists (counselors, psychologists, etc.).

Professional societies, such as the American Medical Association and the American Psychiatric Association, require that their members cooperate and respect colleagues as well as maintain and increase their competency (the two associations' principles of medical ethics may be accessed at and, respectively). However, team-oriented care of alcohol dependence employing different treatment providers traditionally has been difficult because of differences in treatment philosophies, knowledge of issues, and willingness to cooperate or "share" patients. In addition, more than half of addiction treatment programs do not have a full-time physician or nurse who could prescribe medications; thus, there is often a missing connection between prescribers and nonprescribers, which is needed for proper medication management. (1)


Barriers to cooperation

Counselors might not see physicians as their allies in the treatment of alcohol dependence because of the perceived or real deficiencies of physicians in this field. Many physicians do not adequately screen for alcohol dependence (2) or shy away from dealing with patients who have drinking problems. (2,3) Indeed, many physicians have received minimal training in treating addictions, and many might feel unprepared and uncomfortable treating patients with alcohol use disorders. (3) In addition, physicians may not make appropriate referrals, and some counselors might think physicians even compound patients' problems. For example, physicians might prescribe benzodiazepines to help treat symptoms following withdrawal from alcohol. But if these potentially addictive medications are prescribed inappropriately, or if there is inadequate monitoring and follow-up, patients might develop new addictions or problems with these medications.

Another barrier to proper treatment and collaboration between counselors and physicians stems from the views among some physicians that alcoholism is a moral defect rather than an illness. (4) Physicians with these beliefs may think counselors cannot help alcohol-dependent patients or could even enable them. For physicians who lack knowledge or appreciation of alcohol dependence, counselors can serve as an educational resource.

Even among physicians who have experience treating addicted patients, other differences between prescribers and nonprescribers might interfere with the cooperation, communication, and trust required for team-oriented treatment of alcohol dependence. Cooperation can be difficult if there are major differences in opinions regarding treatment; indeed, medication use has traditionally been an issue of contention in alcohol dependence treatment. Some counselors think medications detract from the recovery process by removing some of the necessary difficulties that naturally result from abstinence (for more on these biases, see the third article published in this series, in the May/June 2007 issue). In addition, there is evidence that counselors do not recommend medications to their patients because they are not familiar with them. (5,6,7) This is most likely because many have received little education and training on medication use. (8)

In contrast, physicians prescribe and rely heavily on medications in their practices. This difference in treatment philosophy can be especially problematic because physicians are trained to be team leaders and are accustomed to making most treatment decisions. (9) Many also may lack training or experience working collaboratively with nonphysician team members.

On the other hand, counselors and other nonprescribers might be uncomfortable or even intimidated by working with physicians, especially if there is not a shared method of communication or focus of treatment. For example, many physicians present and discuss patient cases using a medical model that tends to concentrate on the patient's current symptoms and how they may be treated (often with medications) as opposed to a more detailed presentation or discussion of the patient's history and accompanying psychological dynamics. Conversely, some physicians, particularly psychiatrists, may overfocus on the patient's psychological dynamics at the expense of exploring addiction-related issues. Additionally, physicians may concentrate their efforts on the patient's co-occurring diseases--for example, depression, anxiety, or hypertension--while counselors may be more focused on changing the patient's recovery environment to avoid relapse. While these generalizations may be a bit simplified, they highlight some of the differences in style, focus, and expertise between different treatment providers.

Facilitating collaboration

The goal of team-oriented treatment is for each team member to work seamlessly with the others to maximize use of each person's knowledge, skills, and experiences for the benefit of the patient; the whole is greater than the sum of the parts. This collaboration requires the best communication among team members.

Previous articles in this series have emphasized the need for counselors to consider the benefits of medications for each patient they see and to become more familiar with their use. Physicians, for their part, are trained to be familiar and comfortable with consulting other physicians of different specialties--they speak a common medical "language." They tend to be less comfortable in consultations and collaboration with nonphysician professionals. When speaking with medication prescribers, counselors should present patient cases concisely, with a focus on the goals of medication use. They should be assertive without being aggressive, and yet at the same time not be too deferential or take a "hat-in-hand" approach.


It is important that counselors have some knowledge about how medications for alcohol dependence work, their indications, and their potential benefits and side effects. It is somewhat analogous to a contractor building a house. While specific work (plumbing, electrical, etc.) will be subcontracted out to other team members, the contractor must know something about each job being subcontracted. Similarly, counselors should be able to identify the patient's most pressing symptoms and understand which medications are best suited to treat those symptoms, even though they will not prescribe the medications.

For example, a counselor might recognize the anxiety and negative emotional state commonly seen in the weeks and months after drinking has stopped, and suggest to a prescriber that acamprosate be considered. Or a counselor might suggest that naltrexone be looked at for a patient who is obsessed by alcohol cravings and as a result has relapsed on occasion despite earnest efforts at abstinence. For patients who are interested in treatment but who may have risk factors for poor treatment adherence, extended-release naltrexone could be a sensible choice. This working knowledge is important with regard not only to medications for alcohol dependence but also to medications used to treat co-occurring psychiatric disorders, which are prevalent among those with alcohol problems. There are several reputable Web sites that can provide quick access to information on medications, such as from the American Society of Health-System Pharmacists.

Communicating this hands-on knowledge about the patient to the prescriber will help reduce repeated patient assessments by multiple treatment providers and save time, which is important to physicians who might tend to avoid treating patients' addictions because the issues can be extensive and they feel pressed for time.4 This communication also will foster increased trust in the prescriber-nonprescriber relationship. Busy physicians benefit by being able to rely on counselors and others for help in patient assessment, management, and periodic reassessment.

Educational opportunities

Nonprescribers and prescribers have the opportunity to share their different experiences and expertise with each other when collaborating in the treatment of alcohol-dependent individuals. It is in this context of education and information sharing that some of the barriers between treatment providers can be reduced. In addition, adoption of new technologies, such as newer medications for treatment, is more likely when individuals learn about them from colleagues who already have had experience with them. (8)

Physicians and counselors can provide services quid pro quo. Physicians are able to provide prescriptions and share their knowledge about medication use, side effects, and other information that counselors do not necessarily handle on a routine basis. Counselors usually see patients more frequently and for longer durations than physicians, and with this increased patient contact they might be able to help improve patient adherence to medications. Counselors might also help foster better relationships with physicians by giving educational presentations and materials to physicians and their staff. Providing this kind of service in a face-to-face encounter will improve communication and knowledge sharing.

Counselors also should strive to provide education to the medical community and the community at large to help create a greater awareness of the issues surrounding unhealthy alcohol use. This also will help demonstrate the valuable roles counselors play in treatment and, at the same time, will help build counselors' practices through increased patient interest and medical referrals.

Building supportive relationships among treatment providers may be especially important for counselors, who have high rates of emotional exhaustion and burnout, and consequently turnover. (6) There is an estimated 50 to 60% staff turnover rate within two years at treatment programs, with similarly high facility reorganization and closure rates. (1) High rates of counselor turnover make long-term treatment relationships between counselors and physicians very difficult. A lack of meaningful professional relationships can contribute to job dissatisfaction among counselors. Cooperative and effective prescriber-nonprescriber relationships may contribute to greater satisfaction, greater job retention, and less burnout--and that ultimately is likely to translate into better patient care.


Treatment of alcohol-dependent patients may be most comprehensive when delivered by a cooperative team of professionals, in which each member lends his/her expertise to the process. Though barriers to this kind of integrated care persist, counselors, physicians, and other treatment providers can further establish and improve their working relationships by respecting, educating, and actively communicating with one another. These steps will promote optimal use and management of medications and will improve all aspects of treatment.

Thomas J. Brady, MD, MBA, is Vice President and Chief Medical Officer for CRC Health Group. Correspondence may be sent to him at CRC Health Group, 20400 Stevens Creek Blvd., Suite 600, Cupertino, CA 95014; e-mail The Web site address for CRC Health Group is


1. Kimberly JR, McLellan AT. The business of addiction treatment: a research agenda. J Subst Abuse Treat 2006;31:213-9.

2. Edlund MJ, Unutzer J, Wells KB. Clinician screening and treatment of alcohol, drug, and mental problems in primary care: results from healthcare for communities. Med Care 2004;42:1158-66.

3. Miller NS, Sheppard LM, Colenda CC, et al. Why physicians are unprepared to treat patients who have alcohol-and drug-related disorders. Acad Med 2001;76:410-8.

4. Mark TL, Kranzler HR, Poole VH, et al. Barriers to the use of medications to treat alcoholism. Am J Addict 2003;12:281-94.

5. Thomas SE, Miller PM. Knowledge and attitudes about pharmacotherapy for alcoholism: a survey of counselors and administrators in community-based addiction treatment centres. Alcohol Alcohol 2007;42:113-8.

6. Roman PM, Ducharme LJ, Knudsen HK. Patterns of organization and management in private and public substance abuse treatment programs. J Subst Abuse Treat 2006;31:235-43.

7. Thomas CP, Wallack SS, Lee S, et al. Research to practice: adoption of naltrexone in alcoholism treatment. J Subst Abuse Treat 2003;24:1-11.

8. McCarty D, Edmundson E Jr, Hartnett T Charting a path between research and practice in alcoholism treatment. Alcohol Res Health 2006;29:5-10.

9. Saxon AJ, McCarty D. Challenges in the adoption of new pharmaco-therapeutics for addiction to alcohol and other drugs. Pharmacol Ther 2005;108:119-28.

Supported by an educational grant from Alkermes, Inc., and Cephalon, Inc.

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Author:Brady, Thomas J.
Publication:Addiction Professional
Date:Sep 1, 2007
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