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Research Summary

Confidence and Judgment Are Important for Medical Management of Alcohol Dependence

Greater involvement of primary care physicians in the delivery of medication-assisted alcohol treatment would expand treatment access for alcohol use disorders. This secondary analysis of the COMBINE study* examined the influence of patient and clinician factors on drinking outcomes among 1162 patients randomized to receive Medical Management (MM) plus naltrexone and/or acamprosate from 37 clinicians.


  • Clinicians’ ability to convey confidence in the treatment (high ratings on an authoritativeness scale), and flexibility in delivering the intervention (lower ratings on strictness of adherence to the study script) predicted better drinking outcomes.
  • Of the patient variables, number of visits and better perception of the relationship with the clinician predicted better drinking outcomes.
  • Patient satisfaction with MM also predicted increased abstinence and clinical improvement.

*A randomized controlled trial that combined pharmacotherapy with Medical Management (an intervention consisting of 9 brief structured outpatient sessions provided by a health care professional), with or without specialty alcohol treatment.


This subanalysis implies that the confidence, skill, and clinical judgment of the clinician are important in MM for alcohol use disorders. The ability to convey confidence in the treatment inspires hopefulness, an essential element to develop patient self-efficacy. Flexible clinicians with good clinical judgment vary treatment to “meet patients where they are,” and in doing so, build therapeutic alliances and satisfaction. Although much recent research suggests the importance of treatment fidelity to producing the best outcomes, blind adherence to MM treatment guidelines will not optimize the management of alcohol use disorders in primary care settings. Greater emphasis on substance use disorders at all stages of medical education and training is needed to improve primary care clinicians’ confidence, skill, and judgment in identifying and managing these disorders.

Peter D. Friedmann, MD, MPH


Ernst DB, Pettinati HM, Donovan DM, et al. An intervention for treating alcohol dependence: relating elements of medical management to patient outcomes in primary care. Ann Fam Med. 2008;6(5):435–440.