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

We would like to thank Cook for her commentary (Cook, 2015) in this issue of EBioMedicine, which deals with not only our findings (Laramee et al., 2015) 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., 2015a, Mitchell et al., 2012). 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., 2007; 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., 2015), and because of stigmatization tend to postpone interventions until they are unavoidable (Rehm et al., 2015b). Moreover, a recent review did not see much evidence for this kind of referral (Glass et al., 2015). 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, 2014), and this strategy may prove to be the way forward.