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Theresa is a 39-year-old, white, single woman who presents with insomnia and depression. After exploring the presenting symptoms, her physician reviews some screening questions about potentially related problems. In response to a question about heavy drinking in the past year, Theresa responds that she is drinking about 2 bottles (10 drinks) of wine nightly. She acknowledges going over limits repeatedly and a persistent desire to quit or cut down, as well as continuing to drink in spite of hangovers and nausea in the morning. She denies withdrawal symptoms, driving while intoxicated, job or serious relationship problems, but admits that her social activities have decreased over the past year because she spends her evenings drinking alone. No one else knows she is struggling with drinking. Her depression and insomnia started after her drinking increased about 2 years ago.


Excessive drinking of alcohol (Figure 249-1) is a common behavior encountered in primary care, yet few clinicians feel prepared to address it. Most clinicians are unclear about the best way to screen for heavy drinking and lack confidence in how to address it. Physicians often lack the knowledge and skill to screen and evaluate excessive drinking, let alone address it other than suggesting a referral to an addiction counselor or treatment program. Regrettably, few patients accept referral to a counselor or program. Fortunately, research over the past 20 years has provided evidence-based, efficient ways to screen, evaluate, and treat heavy drinking in primary care.

FIGURE 249-1

The Drinkers by Jean Béraud depicting a disheveled man pouring another drink of alcohol as a cigarette dangles from his mouth. The woman looks directly at us as she appears ready to leave with her handbag on the seat. She is dressed for a night out and appears to have expected more than sitting in a booth as her male partner drinks himself into oblivion. Painted in France in 1908 but touches us even today, as alcoholism is a worldwide and universal human issue.


Heavy drinking refers to drinking in excess of low-risk guidelines (see below).

Alcohol dependence (alcoholism) is a disorder of compulsive drinking associated with impaired control over intake, such as repeatedly exceeding self-defined limits, a persistent desire to quit or cut down and difficulty doing so, and continued use despite adverse consequences.

The terms alcohol use disorder, alcohol dependence, and alcoholism can be used interchangeably.


  • In any given year, approximately 30% of U.S. adults 18 years of age and older exceed the National Institute on Alcohol Abuse and Alcoholism (NIAAA) low-risk drinking guidelines at least once.1 The low-risk drinking limits for healthy adult women is defined as drinking no more than 3 drinks ...

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