Alcohol consumption is among the leading causes of preventable death worldwide, with three million deaths attributable to alcohol consumption per year [1] . Moreover, the harmful use of alcohol causes approximately 5.9% of all deaths annually, and 5.1% of the global disease burden is attributable to alcohol consumption [2] .

Alcohol use disorder (AUD) is a chronically relapsing disorder characterized by a compulsion to ingest alcohol, loss of control in limiting alcohol intake despite adverse health, social and occupational consequences, and the emergence of a negative emotional state involving feelings of anxiety, irritability and dysphoria when access to alcohol is prevented [3] . It is estimated that 107 million people worldwide suffer from AUD, which causes 2.8 million premature deaths every year [4] . Chronic alcohol consumption damages multiple systems of the human body, including the cardiovascular, gastrointestinal, and nervous systems [5] .

According to a 2023 survey conducted by the Japanese Ministry of Health, Labour, and Welfare, 119,000 people in Japan suffer from AUD [6] . Primary care physicians in Japan are expected to provide basic standards of care and fulfill the unmet needs of the population. Therefore, they must be involved with patients with AUD and manage AUD-related symptoms. In this study, we reviewed the difficulties in managing AUD and how primary care physicians are expected to work with patients with AUD.

There are several evidence-based interventions for AUD that are utilized in primary care. We have discussed below some of the popular ones.

The Diagnostic and Statistical Manual for Mental Disorders, 5^th edition defines AUD as a pattern of alcohol consumption, leading to problems associated with two or more of the 11 potential symptoms of AUD [18] . Therefore, AUD is a definite mental disorder. AUD is accompanied by changes in key brain areas that can persist even after alcohol use cessation. Additionally, it may result in excessive salience to alcohol-related cues, changes in the motivational properties of natural rewards, an altered and exaggerated response to stress, and difficulties with executive control and self-regulation [19] . Moreover, patients with AUD tend to have other mental disorders along with AUD. Depressive disorders are the most common psychiatric disorders among people with AUD and the co-occurrence of these disorders is associated with heightened risk for suicidal behavior [20] [21] . A study on patients with bipolar affective disorder (BD) recruited from the Stanley Foundation Bipolar Network outpatient clinic with more comprehensive care reported AUD in 33% of patients with BD [22] . Therefore, psychiatric knowledge is required to manage patients with AUD.

Proactively assessing mental disorders, at least in patients with complaints related to alcohol is important, not only by addiction specialists, but also by primary care physicians. However, this may be an idealistic policy.

Although primary care physicians play an important role in addressing patients’ mental health needs and providing access to care [23] , there are several challenges for primary care physicians worldwide in treating patients with psychiatric disorders.

In India, cannabis is one of the most commonly used illicit substances, and primary care physicians are the first contacts for the majority of patients with psychiatric disorders across India. However, they are not adequately trained to treat psychiatric and substance use disorders [24] [25] . Conversely, networks have been established to support primary care physicians in some countries. For instance, in Spain, community mental health professionals work in a coordinated and interdisciplinary manner with primary care teams based on a community model of care for people with mental health problems to provide comprehensive care [26] .

A face-to-face household survey conducted in four communities in Japan reported that the prevalence of mental disorders was equal to that observed in Asian countries. However, the percentage of those receiving medical treatment was low, even for those with severe or moderate disorders [27] . Furthermore, a mixed-methods study (28 in-depth interviews and 315 survey responses) conducted to identify the educational gaps of general practitioners in Asia-Pacific countries reported a strong need for education on mental disorders [28] . Therefore, primary care physicians have limited knowledge in treating mental disorders.

Hence, to provide comprehensive care to the patients, Japan should adapt Spain’s progressive initiatives in Japan’s future national mental health strategies.

The stigma associated with mental illness contributes significantly to the burden of mental illness and leads to disadvantages in many aspects of life, including personal relationships, education, and work [29] . According to Link and Phelan, stigma exists when the following interrelated components converge:

These components lead to the identification of differences; construction of stereotypes; separation of labeled persons into distinct categories; and full execution of disapproval, rejection, exclusion, and discrimination [30] .

AUD is one of the most stigmatized disorders in the Western countries [31] . Individuals with AUD tend to be viewed as more responsible for their disorder, and elicit more social rejection and negative emotions than those with other disorders [32] . This stigmatization has been reported to be stable over time [33] . A public opinion poll conducted by the Cabinet Office, Government of Japan regarding the image of AUD, found that 51.7% of respondents think that patients with AUD are abusive and violent, 46.7% think they drink during the daytime instead of going to work, and 34.7% think the reason for the illness is the patient’s weak will [34] . The stigma against AUD has also become widespread among the Japanese public.

Due to the influence of stigma, some people with mental illness may accept the discrediting prejudices held against them and thus lose self-esteem, leading to feelings of shame, a sense of alienation, and social withdrawal [35] [36] . However, among individuals with AUD, a preference for seeking treatment in primary care centers has been observed. Additionally, some Swedish studies have shown that most individuals with AUD prefer seeking specialist care within the healthcare services [37] [38] . Primary care physicians are responsible for ensuring that individuals with AUD are evaluated and cured without the influence of stigma. However, primary care physicians alone are not knowledgeable enough to provide appropriate treatment for AUD patients. Furthermore, reports show that stigma is present among physicians and correlates with unequal treatment of patients [39] . The strategy against stigma for healthcare disparities suggests that all physicians should acknowledge their susceptibility to stigma and health facilities should standardize measures addressing stigma at multiple ecological levels for a sustainable response [39] [40] .

Herein, we report a case of AUD that required hospitalization for an internal disease. This case shows how AUD is interrelated with both physical and psychiatric challenges, and how the collaboration between the primary care physician and psychiatrist was beneficial in treating the patient.

Dealing with patients with AUD in a busy clinical setting can be exhausting and frustrating. However, we must put aside the stigma against AUD and work with patients to find remedies through trial and error, with the cooperation of psychiatrists and other multidisciplinary professionals. We believe that the most important form of support for patients with AUD to overcome their own stigma is careful medical care by primary care physicians who are engaged in community medicine and have a good understanding of the patients’ social and lifestyle backgrounds.

We would like to thank Editage ( https://www.editage.jp/ ) for English language editing.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

At our institution, review articles do not require approval from the ethics committee for publication. Therefore, institutional approval was not required to publish this study.

Consent was obtained from all the patients by the corresponding author. Patient details were anonymized as much as possible.

TT, KK, and HF contributed substantially to the conception and design of the study and to the acquisition, analysis, and interpretation of data. All authors agree to be responsible for all aspects of the work and ensure that any questions related to the accuracy or completeness of any part of the work are appropriately investigated and resolved. All authors contributed to and approved the submitted manuscript.