Alcohol is probably one of humanity's oldest drugs, and is the most widely used drug in the Australian community.1 In this issue of the Journal (page 103), the article by Graham and colleagues, on newer pharmacotherapies to help people with alcohol dependence,2 highlights specific interventions that general practitioners can use to help their patients with more severe alcohol-related problems.

It is worth noting that most of the morbidity associated with alcohol use does not occur in people with dependence, but rather in those who have hazardous or harmful drinking patterns. The National Mental Health and Wellbeing Survey indicated that, among young men aged 18–24 years, the prevalence of harmful use of, or dependence on, alcohol was over 20%.3 The 1998 National Household Drug Survey found that 18% of people surveyed admitted to driving, 30% admitted to verbally abusing another person, and 2% admitted to physically assaulting another person while under the influence of alcohol.1 The acute health and social effects of alcohol intoxication are just as devastating as the long-term effects of chronically excessive alcohol consumption.

Many GPs have negative perceptions of dealing with people who have alcohol and other drug-related problems.4 However, GPs can be very effective at altering the consumption habits of non-dependent drinkers.5 If the matter is raised, most Australians who drink too much will respond to a structured discussion with their GP about their alcohol consumption patterns. This may be where the general practice "main game" ought to be. The first step in managing people with alcohol-related problems is to identify them, and currently the AUDIT questionnaire is accepted as the most appropriate screening tool in the general practice setting.6 A copy can be found in the recent Guidelines for preventive activities in general practice.7 Screening of all Australians over the age of 15 is recommended.

Brief intervention (see the Box) involves GPs raising the question of alcohol intake, and determining whether patients might consider changing their levels of consumption. If so, then risks and benefits of drinking are explored, strategies for reducing alcohol intake to safer levels are presented, goals are set, and follow-up is arranged. If patients do not wish to discuss their drinking, they can be given some printed information and the door left open for them to return if they change their minds. The intervention is quick and easily learnt. Many Divisions of General Practice across Australia offer training in brief intervention and motivational interviewing.

GPs can also help their patients overcome alcohol dependence, but interventions for this require more time. Detoxification in the community, supervised by GPs, can be a safe option,8 and rural GPs supervise hospital-based detoxification on a regular basis. The use of anti-relapse medications such as acamprosate or naltrexone can help alcohol-dependent patients remain abstinent once they have undergone detoxification. However, as such patients ideally require counselling and support from professionals specifically trained in addiction, the GP's role is as a member of a team. The medication is only part of the assistance package.

It should also be remembered that screening and therapeutic interventions for alcohol problems are just one of many competing demands on GPs. High blood pressure; diabetes; smoking; screening for breast, cervical and colorectal cancer; depression; domestic violence; falls — the list of competing preventive priorities seems endless. Where should alcohol fit into all of this? What are the opportunity costs? What are the workforce ramifications of these types of preventive activities? Is there spare capacity within general practice to address these tasks?

Clinical practice guidelines and recommendations about preventive activities are positive developments in themselves, but are rarely accompanied by any consideration of whether they are possible to implement on a broad and equitable basis. Despite significant philosophical shifts within general practice and a growing acceptance of the value of prevention, the dominant medical model remains diagnosis and treatment. This pervades the way that general practice functions, the way it is structured and the way it is remunerated. In a recent survey of general practice in 2000–2001,9 alcohol-related activities did not rate in the "top 30" most frequently managed problems. This reflects a reality that most health bureaucrats are reluctant to acknowledge — what is being asked of general practice is often beyond its capacity to provide. The GP is stuck in the middle, trying to respond to the community demand for diagnosis and treatment, while at the same time being asked to do more and more on a preventive level. The pertinent question as to whether the (usually population health) problem is best tackled through the medical model is almost never asked. There are often other approaches to these issues that are more effective, but might be politically unpalatable. In the case of alcohol misuse, reducing access though higher levels of taxation (resulting in a higher price), targeting public education campaigns, restricting advertising, random breath testing and increasing penalties for drink driving are all effective methods of reducing alcohol-related morbidity and mortality. In short, alcohol consumption is best addressed by public policy.

General practice needs to focus on what it does best: diagnose and treat. There will be some circumscribed areas of prevention where the medical model fits well or where it is an important part of the whole picture. If we decide that alcohol consumption is one such area, then general practice needs to be adequately resourced to undertake this new task. However, there will be opportunity costs. There is good evidence that we can have a positive impact on alcohol consumption patterns, but we currently do not focus on this area in a substantial way because of real competing priorities that our community has placed before us.