November 2016 | Volume 4 | Article 2641
MINI REVIEW
published: 29 November 2016
doi: 10.3389/fpubh.2016.00264
Frontiers in Public Health | www.frontiersin.org
Edited by:
Sandra C. Buttigieg,
University of Malta, Malta
Reviewed by:
Habib Nawaz Khan,
University of Science and
Technology, Pakistan
Guenka Ivanova Petrova,
Medical University Soa, Bulgaria
*Correspondence:
Mirjana Ratko Jovanovic
Marko Antunovic
Specialty section:
This article was submitted
to Health Economics,
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Frontiers in Public Health
Received: 15June2016
Accepted: 10November2016
Published: 29November2016
Citation:
JovanovicM and AntunovicM (2016)
Person- and People-Centered
Integrated Health Care for Alcohol
Dependence – Whether It Is Real in
the Present Moment.
Front. Public Health 4:264.
doi: 10.3389/fpubh.2016.00264
Person- and People-Centered
Integrated Health Care for Alcohol
Dependence – Whether It Is Real
inthe Present Moment
Mirjana Jovanovic
1
* and Marko Antunovic
2
*
1
Department for Addiction and Dual Disorders, Clinical Center, Psychiatrist/Psychiatric Clinic, Kragujevac, Serbia,
2
National
Poison Control Center, Military Medical Academy, Belgrade, Serbia
Alcohol continues to occupy a leading position in Europe as a popular substance of
abuse. According to WHO sources together with cigarette smoking and obesity, alcohol
is a major cause of preventable diseases. Harmful use of alcohol is one of the main
factors contributing to premature deaths and disability and has a major impact on public
health. The consequences of alcohol use on human health are enormous. Additionally,
alcohol use can have harmful effects that do not directly affect person who consumes
alcohol (e.g., fetal alcohol syndrome violations that are related to alcohol use, etc.). It is
well known that the harmful effects and consequences of alcohol use (e.g., acute and
chronic illness, injuries in ghts, at the workplace, in trafc, violent behavior, and death)
create a great burden for the economic development of society. Persons who have been
diagnosed with alcoholism and currently drinking have a less chance to achieve a life
insurance cover. On the contrary, recovering alcoholic with a signicant abstinent period
can get a good life insurance quote. The abstinence of a year or 2 is usually enough
for a person to get an average price of life insurance. Furthermore, new consequent
relapses could also be considered as potential aggravating factor to accomplish this kind
of nancial benets. So far, the research (and interventions) focused on the effects on the
population level, such as the increase in taxes, advertising bans, and the implementation
of laws that prevent the use of alcohol in trafc. However, it seems that the problem
may be viewed at the individual level. The models of the treatment should be designed
according to the needs of the individual. These models should incorporate not only the
reduction of alcohol intake but also the path to abstinence. The plan should take into
account the different (individual) needs for treatment, with regard to the degree of alcohol
dependence and health status and also include the needs of the family, community, and
broader society.
Keywords: alcohol addiction, insurance, person integrated health care, harmful use of alcohol, social costs
Alcohol continues to occupy a leading position in Europe as a popular substance of abuse. Together
with cigarette smoking and obesity, alcohol is a major cause of preventable diseases. Although
alcohol consumption is relatively stable per capita, an increase was observed in North and Eastern
Europe, while a decrease in consumption has been observed in countries where wine is traditionally
consumed (1).
2
Jovanovic and Antunovic Health Care for Alcohol Dependence
Frontiers in Public Health | www.frontiersin.org November 2016 | Volume 4 | Article 264
Alcohol abuse and alcohol dependence are two entities that
have been included in the previous Diagnostic and Statistical
Manual of Mental Disorders (DSM) IV classication. However, in
the DSM V classication, these disorders are part of a continuum
called alcohol use disorders. ese disorders are classied as
mild, moderate, and severe, depending on fullled criteria for
diagnosis (2).
As WHO experts concluded, alcohol dependence is one of the
world’s leading risk factors for morbidity, disability, and mortal-
ity. Harmful use of alcohol is the root of more than 200 diseases
and injuries described in the ICD-10 classication (3).
Harmful eects are proportionate to the amount of alcohol
consumed. e consequences become more drastic as the
amount of alcohol increases. e largest number of dangers to
health and mortality come from heavy drinking. About 80% of
deaths of men associated with alcohol use are the consequences of
heavy drinking, and as much as 67% of deaths of women. Heavy
drinking means consuming at least 60mg/day, of ethyl alcohol for
men, and 40mg/day for women (4).
By “Global status report on alcohol and health” of World
Health Organization (5), alcohol consumption leads to 3.3
million or 5.9% of lethal outcomes per year (5). e number is
greater than mortality from HIV/AIDS, which is 2.8%, violence
which is 0.9%, and tuberculosis which is 1.7%. Additionally,
5.1% of global costs associated with repercussions of alcohol
use are spent on diseases and injuries which are a direct conse-
quence of alcohol use [measured in disability-adjusted life years
(DALYs)] (5).
e consequences of alcohol use on human health are enor-
mous. Additionally, alcohol use can have harmful eects that do
not directly aect the person who consumes alcohol (e.g., fetal
alcohol syndrome, violations that are related to alcohol use, etc.).
Also, the harmful eects and consequences of alcohol use (e.g.,
acute and chronic illness, injuries in ghts, at the workplace, in
trac, violent behavior, and death) create a great burden for the
economic development of a society.
In Europe, the costs associated with alcohol abuse are around
€155.8 billion (6). Alcohol is one of the most important causes of
mortality and also a signicant devastating factor when it comes
to individual and general social welfare. e family also suers
numerous negative eects that result from alcohol abuse.
In addition, alcohol abuse signicantly aects the ability
to work, both with respect to performance and days on sick
leave(6).
For example, in the USA, the cost of alcohol abuse along with
all the consequences were around $249.0 billion in 2010 (7).
As for the total cost in the USA, it has been calculated that
three-quarters of the costs of alcohol abuse are associated with
binge drinking.
In the context of premature death and disability, concluded
Lim and colleagues, alcohol misuse is listed as a h risk fac-
tor in general, but positioning to the rst place among people
between ages of 15 and 49years (8). Also, approximately 25% of
total number of deaths in the age group 20–39years are associated
with alcohol use, according to WHO (9).
Alcohol harmful use may have signicant impact on social
aspects and economic costs.
e WHO Global Status report on alcohol and health in 2014
reported:
e most prevalent tendency worldwide is an increase
in recorded alcohol per capita consumption. is trend
is mainly driven by an increase in alcohol consumption
in China and India, which could potentially be linked to
active marketing by the alcohol industry and increased
income in these countries. e ve-year trend in the
WHO African Region, WHO European Region and,
particularly, the WHO Region of the Americas is mainly
stable, although some countries in the WHO European
Region and the WHO African Region report signicant
decreases in alcohol consumption (1).
According to Anderson (1), there are ve dierent interven-
tion models considered to be ecacious based on the results
of clinical trials: pharmacotherapy with counseling, cognitive
behavioral therapy, motivational interviewing, and two models
of brief interventions (1).
In dierent parts of the world, there are dierences in the
amount of drinks per capita. e dose of ingested alcohol also
plays an important role with regard to the consequences. When
it comes to injuries, the most important is the concentration
of alcohol in the blood, while the chemical composition of
alcoholic beverages aects the general state of health to a lesser
extent (10).
Dierent societies and countries are taking legal measures in
order to restrict the availability and use of alcohol, for example,
limiting the size and/or increasing the price of beverages. Such
measures are having an immediate, although limited eect (11).
As for the policy in this eld, it is important to point out,
according to research AMPHORA, that any limitation of alcohol
consumption (permissible level of alcohol in the blood) leads to
the reduction of the use of alcohol (12).
At the micro level: each reduction of the alcohol dose that is
consumed, either by reducing the frequency of drinking or by
reducing the quantity of alcohol consumed has an immediate
impact on reducing the number of cardiovascular events and
all kinds of injuries. is is particularly pronounced in heavy
drinking.
As for the situation in Serbia, which is the central country of
the Western Balkans, Djordjevic and his colleagues concluded
that the pattern of drinking at a scale of 1–5 (the most risky form
of drinking) is estimated at 3. As for the adolescent population in
Serbia, 97.4% of them consumed alcohol and 34.9% of adolescents
had the rst experience with alcohol before 14years of age, which
coincides with the cultural pattern. Namely, in Serbia, children
(especially male children) are allowed to try alcohol in a family
environment, and it is considered a kind of test of manhood (13).
It is not surprising that the total social costs of alcohol abuse,
both direct and indirect, are high. Direct costs are related to
direct harmful eects of alcohol consumption (12). Indirect costs
encompass loss of productivity, loss of quality of work, and so on.
Even some studies show that the social costs (direct) are higher
than medical costs, and indirect costs are even higher than the
direct costs (14).
3
Jovanovic and Antunovic Health Care for Alcohol Dependence
Frontiers in Public Health | www.frontiersin.org November 2016 | Volume 4 | Article 264
HEALTH INSURANCE
According to the World Health Organization alcohol consump-
tion per capita is expected to increase up until 2025 (5). e
largest increase is expected in the Western Pacic (dominantly in
the Chinese population). Estimates are that growth will be about
1.5l of pure alcohol per capita. e increase is expected in the
Americas and South-Eastern Asia too (5). All these changes will
certainly have signicant repercussions not only on the nancial
burden but also on physical and mental health and narrower and
broader social consequences.
From the perspective of payers, cost estimation is very impor-
tant. e starting point for health economic analysis and decision
making requires consideration of not only cost but also outcomes.
Most health insurance policies in the EU and USA will not
cover all alcohol abuse treatments or rehab expenses. Typically,
there are always some out-of-pocket costs.
It is a simple calculation, considering that health insurance
covers a shorter hospital stay – the treatment usually remains
on that level. Short hospitalizations are not sucient to enable a
patient to achieve a stable psycho-physical condition, so the level
of health care that a patient receives does not correspond to their
real needs. is just leads to poor treatment outcomes, frequent
relapses, repeated hospitalizations, and nally, to more costs (11).
Also, it usually means that new relapses in a short period of time.
ese and similar situations are cause for a new cycle of problems
with insurance.
e questions concerning alcohol abuse or problems associated
with the cost of treatment and insurance are evaluated periodi-
cally, both in professional circles and in the media. According to
the sources listed in the report by http://HBO.com, many people
are struggling with substance addiction, as well as with the lack
of treatment because of insurance limitations (15).
In fact, everything that relates to extended treatment is not
covered by insurance as well as rehabilitation programs.
According to information from the same source, the economic
share of untreated alcohol dependence is $325 billion per year.
Also, if a person is adequately treated (adequate therapy and
length of treatment), $7–$12 on every dollar spent are saved (16).
Despite calculation and everyday clinical practice, patient’s
real needs are ignored by medical and other professionals. At the
end, patients are faced with a closed circle.
e National Health Insurance Fund organizes the health-
care system for all citizens and permanent residents, but with
obligations for employees, self-employed persons, and pension-
ers to contribute. e wealthier members of society need to
participate with higher percentage of their income, based on
a specied sliding scale. is method of nancing is a residue
of the socialist system of health insurance, but in recent years,
this system has undergone serious changes (harmonization with
EU law).
For example, research results show that the total allocation for
health amounted to 8.13% of the gross domestic product (GDP)
in 2003, whereas in 2014, it amounted to 9.91% of the GDP. e
share of foreign donations in health nancing decreased from
1.7% of the GDP in 2003 to 0.46% in 2014. Within the public
sector funders of health care in Serbia, it has been found that the
predominant funder was the Republican Health Insurance Fund
(NHIF) with a share of 91.2% in 2003 and 93.99% in 2014 (15, 17).
Although the nancial commitment by the NHIF increased, it
eventually became insucient because of increased costs incurred
as a result of the growing needs of the population. e average
patient (oen with good reason) is dissatised with health care
and the fact that they have to wait for an “ordinary” ultrasound
a month or 2, and up to a year for a MRI, while for many drugs,
they have to pay 90% of the original price.
In EU countries, national health systems face dierent kinds
of major nancial challenges (18).
SITUATION WITH LIFE INSURANCE
Many insurance companies, for example, in the UK, treat alco-
holism as a disease. Of course, there are certain limitations con-
cerning insurance. According to WHO sources, the maximum
level of alcohol intake per week is 21U for men and 14U for
women (1). In any case, insurance companies paradoxically do
not require medical examinations for people who consume more
than 40U a week (an alcoholic unit is equivalent to half pint of
beer or one glass of wine). It is questionable whether this kind
of model reduces total treatment costs of patients suering from
alcoholism or increases it (19).
e Medical Report or record from a GP contains all the
important information about the health condition of the patient.
Section from the medical record considering occasional
drinking provides information about person’s average consump-
tion. Data about dependents and marital status are included into
family section. Employer section provides information not only
about current employment and person’s responsibilities at work
but also regarding possible alcohol intrusion. e insurance
companies in UK are not obliged to contact the employer. Persons
who have been diagnosed with alcoholism and currently drink-
ing have a less chance to achieve a life insurance cover. On the
contrary, recovering alcoholic with a signicant abstinent period
can get a good life insurance quote. e abstinence of a year or
2 is usually enough for a person to get an average price of life
insurance. Furthermore, new consequent relapses could also be
considered as potential aggravating factor to accomplish this kind
of nancial benets.
e General Assembly of United Nations (UN) adopted
in 1991. A wide-ranging set of provisions entitled “Principles
for the Protection of Persons with Mental Illness and for the
Improvement of Mental Health Care.” According to Principle 4
of this important UN document (20, 21) (Table1).
e stigmatization is more powerful than obeying the human
rights. is applies to mentally ill individuals, or even more to
addicts who are doubly stigmatized. In an attempt to initiate
a more equitable access to treatment and aect inequality, in
2014, e International College of Person-Centered Medicine
(the ICPCM) oered a new perspective of integrative health
care oriented toward individuals and was formulated within the
framework of the Geneva Declaration (20), which is as follows:
As global health challenges evolve, health care systems
must include improved eorts to promote wellness,
TABLE 1 | Principles for the protection of persons with mental illness and
for the improvement of mental health care (UN, 1991).
• A determination that a person has a mental illness shall be made in
accordance with internationally accepted medical standards.
• A determination of mental illness shall never be made on the basis of political
economic or social status or membership in a cultural, racial, or religious
group or for any other reason not directly relevant to mental health status.
• Family or professional conict, or non-conformity with moral, social, cultural,
or political values or religious beliefs prevailing in a person’s community, shall
never be a determining factor in the diagnosis of mental illness.
• A background of past treatment or hospitalization of a patient shall not of itself
justify any present or future determination of mental illness.
• No person or authority shall classify a person as having, or otherwise indicate
that a person has, a mental illness except for purposes directly relating to
mental illness or the consequences of mental illness.
4
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Frontiers in Public Health | www.frontiersin.org November 2016 | Volume 4 | Article 264
prevention, and eective chronic disease management.
Health systems that xate excessively on diseases and
procedural interventions can lose sight of the person
with the disease and the importance of that person’s life,
family, and community. is has led to fragmentation
of health care and has le most health care systems less
eective and less ecient in achieving better population
health outcomes. In many ways, the business of disease
has overshadowed the provision of person-centered
healthcare.
By analogy with the conclusion of a group of researchers
proposed a new principle of health care, it can be said that all
national health-care systems should be based on the principles of
person-centered and community-based primary health care as a
point of rst contact of patients with the health-care system and
the usual sources of patient care (20).
e heaviest burden of health risk and disease was observed in
poor subpopulations of the poorest countries. e fact is that the
people’s life chances varies not only because of poverty but also
socioeconomic inequality. As part of the dierentiation of society,
numerous health problems that alcoholics have become more
complicated as they go down the social scale (as they inevitably
will, eventually), as well as more complex and more dicult to
solve. Eventually, alcohol abuse leads to an escalation of anti-
social behavior such as violence, drug abuse, criminal behavior,
neglect and abuse of children, and to other problems including
obesity, depression, and suicidal behavior. It is well known that if
social inequality is present, bad outcomes (with regard to disease
progression and consequences) can be expected both in individu-
als at the top and the bottom of the social hierarchy (22, 23).
WHAT DOES IT MEAN?
Drinking alcohol in excess in any case represents a double
risk (24).
Good intentions? Is it possible in the modern society where
everything is subordinated to the welfare of the small number of
people completely reversing the concept of disease and health,
and to give everyone a chance to survive?
How can we do that? So far, the research (and interventions)
focused on the eects on the population level, such as the increase
in taxes, advertising bans, and the implementation of laws that
prevent the use of alcohol in trac. However, it seems that the
problem may be viewed at the individual level.
In any case, the models of the treatment should be designed
according to the needs of the individual. ese models should
incorporate not only the reduction of alcohol intake but also the
path to abstinence. e plan should take into account the dier-
ent (individual) needs for treatment, with regard to the degree of
alcohol dependence and health status, and also include the needs
of the family, community, and broader society.
AUTHOR CONTRIBUTIONS
MJ has developed main stream of ideas, has done literature
search, and wrote the key theses. MA has done research and
development of some of the basic theses.
FUNDING
e Ministry of Education Science and Technological
Development of the Republic of Serbia has funded the under-
lying study behind reported results through Grant OI 175014.
Publication of results was not contingent to Ministry’s censorship
or approval.
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Conict of Interest Statement: e authors declare that the research was con-
ducted in the absence of any commercial or nancial relationships that could be
construed as a potential conict of interest.
Copyright © 2016 Jovanovic and Antunovic. is is an open-access article distributed
under the terms of the Creative Commons Attribution License (CC BY). e use,
distribution or reproduction in other forums is permitted, provided the original
author(s) or licensor are credited and that the original publication in this journal
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