USPSTF: Screen All Adults for Unhealthy Alcohol Use
June 08, 2018
About 88,000 people die each year from preventable alcohol-related causes.
That’s the word from the U.S. Preventive Services Task Force (USPSTF), which posted a draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) on screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults.
Based on its review of the evidence, the USPSTF recommended primary care clinicians screen all adults 18 and older, including pregnant women, for unhealthy alcohol use. If patients are found to be engaged in risky or hazardous drinking, clinicians should provide them with brief behavioral counseling interventions to reduce unhealthy alcohol use. This is a “B” recommendation.(www.uspreventiveservicestaskforce.org)
“The task force once again found that screening adults and providing brief counseling in primary care settings can help detect and reduce unhealthy alcohol use,” said USPSTF member Carol Mangione, M.D., M.S.P.H., in a news release.(www.uspreventiveservicestaskforce.org) “Addressing this issue among pregnant women is especially important since alcohol use in pregnancy can lead to birth defects and developmental problems.”
Task force members said current evidence is insufficient to assess the balance of benefits and harms of screening and providing behavioral counseling interventions in primary care settings for patients ages 12-17 — an “I” statement.
“Due to lack of evidence in the adolescent population, we simply don’t know if screening and providing counseling to adolescents in primary care settings help reduce alcohol use,” noted USPSTF Chair Sue Curry, Ph.D., in the release. “Until we have more evidence, we continue to call for more research and encourage primary care clinicians to use their judgment when deciding whether to screen adolescents.”
The task force defined unhealthy alcohol use as drinking beyond recommended limits. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends that(www.niaaa.nih.gov)
men drink no more than four drinks per day and no more than 14 drinks per week and
women drink no more than three drinks per day and no more than seven drinks per week.
Screening entails physicians asking patients a series of questions about how often they drink and other drinking patterns. If patients are found to be engaging in risky or hazardous drinking, physicians should provide brief behavioral counseling interventions to reduce unhealthy alcohol use, said the task force. These brief interventions typically include discussing how the patients’ drinking compares to recommended limits and ways to reduce drinking.
Patients who appear to have a more severe alcohol use disorder (AUD), may be referred for more extensive treatment.
This draft recommendation statement is consistent with the USPSTF’s 2013 final recommendation,(www.uspreventiveservicestaskforce.org) which the AAFP agreed with at the time.
In its 2013 recommendation, the task force used the term “alcohol misuse” to define a wide range of drinking behaviors (e.g., risky or hazardous alcohol use, harmful alcohol use, and alcohol abuse or dependence). However, in the current draft recommendation, the USPSTF uses the American Society of Addiction Medicine’s term “unhealthy use,” which is defined as any use of alcohol that increases the risk of health consequences or has already led to health consequences, including an AUD diagnosis.
Draft Recommendation Details
The USPSTF commissioned a systematic evidence review to update its 2013 recommendation on this type of screening. That evidence review examined the effectiveness of screening to reduce unhealthy alcohol use, morbidity, mortality or risky behaviors, and to improve health, social or legal outcomes.
The task force also assessed the accuracy of various screening approaches; the effectiveness of counseling interventions to reduce unhealthy alcohol use and improve patient outcomes; and the harms of screening and behavioral counseling interventions.
Medical treatment was not covered in the review because prescriptions used to treat severe AUD aren’t routinely used in screen-detected patients. Interventions to prevent alcohol use in adolescents also were considered to be outside the scope of this review.
As for screening tools, the USPSTF determined that one- to three-item screening instruments are the most accurate to assess unhealthy alcohol use in adults. Such instruments include the abbreviated Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and the NIAAA-recommended Single Alcohol Screening Question (SASQ). The task force discounted use of the well-known Cut down, Annoyed, Guilty, Eye-opener (CAGE) tool because it detects only alcohol dependence and not the full spectrum of unhealthy alcohol use.
The USPSTF also found that behavioral counseling interventions for unhealthy alcohol use varied in their specific components, administration, length and number of interactions. Nearly all interventions included four or fewer sessions, with a median of one session. The median time of contact was 30 minutes, and most interventions consisted of two hours of contact time or less.
Interestingly, 30 percent of interventions the USPSTF reviewed were web-based.
The task force also noted that primary care settings often used the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach.
Most interventions involved participants receiving general feedback (e.g., how their drinking fits with recommended limits, how to reduce alcohol use).
“The most commonly reported intervention component was use of personalized normative feedback sessions in which participants were shown how their alcohol use compares to others’; more than half of the included trials and almost all trials in young adults used this technique,” the draft recommendation noted.
This type of normative feedback was often combined with motivational interviewing or more extensive cognitive behavioral counseling.
“Other cognitive behavioral strategies, such as drinking diaries, action plans, alcohol use ‘prescriptions,’ stress management or problem-solving were also frequently used,” said the recommendation statement.
About one-third of the intervention trials that included general and older adult populations involved a primary care team.
Finally, the USPSTF found no evidence to suggest that patients’ race, ethnicity or socioeconomic status affected how likely they were to benefit from these interventions; effects of interventions were similar in men and women.
Family Physician Expert’s Perspective
Roger Zoorob, M.D., M.P.H., who is Richard M. Kleberg Sr. Professor and chair of the Department of Family and Community Medicine at Baylor College of Medicine in Waco, Texas, helped create the AAFP’s alcohol screening practice manual.(466 KB PDF) Created through a partnership between the AAFP and the Baylor College of Medicine Practice and Implementation Center, the manual was supported by funding from the CDC.
“The Addressing Alcohol Use Practice Manual guides physicians through a step-by-step process of alcohol screening and brief intervention and how to implement it in practice,” Zoorob told AAFP News. “Additionally, it addresses barriers to implementation and how to select and work with office champions to implement the process.”
The manual includes useful tips and resources such as information on how to evaluate your practice’s environment and workflow; a coding and billing overview; and an implementation plan checklist.
“It allows practices to see what changes can reasonably be made to start screening for alcohol use,” said Zoorob. “The manual itself can be used as a stand-alone resource to help practices take that first step in implementing an alcohol screening protocol in their clinic.”
Family physicians are in an ideal position to obtain information from patients regarding their alcohol use, Zoorob noted.
“Unfortunately, many people are simply unaware that their ‘social’ drinking rises to the level of risky drinking,” he said. “Drinking at a risky level can lead to a host of problems, including motor vehicle crashes; arrest; intimate partner violence; and medical problems that include hypertension, gastritis, liver disease or cancer. This makes screening for alcohol use a priority to educate patients on the dangers of risky drinking.”
According to Zoorob, taking steps to standardize and normalize screening for alcohol abuse makes implementation easier.
“This might look different depending on each practice and their corresponding flow, but it can be as simple as adding a validated one- or three-question alcohol screen during a yearly intake questionnaire,” he said.
If a patient screens positive, that allows the physician an opportunity to dialogue with that patient about the results.
“And if the patient is open to talking about the issue, a brief intervention can be completed in a simple three-to-five-minute conversation,” Zoorob said. A typical behavioral intervention uses validated processes such as motivational interviewing, stages of change and decisional balance.
“Also, tying alcohol use to a relevant current health problem can make it easier to have this conversation with the patient and engage them on why their drinking might be an issue,” he said.
As for pregnant patients, Zoorob said it’s important for them to know that no amount of alcohol is safe during pregnancy.
“Family physicians can play a pivotal role in identifying women at risk for alcohol exposure during pregnancy,” he said. “When a practice starts screening all patients, this allows for all women of childbearing age to be screened and, if needed, be made aware of the concerns of risky drinking, especially if they plan on becoming pregnant.”
The USPSTF is inviting comments on its draft recommendation statement (www.uspreventiveservicestaskforce.org) and draft evidence review.(www.uspreventiveservicestaskforce.org) The public comment window is open until 8 p.m. EDT on July 2. All comments received will be considered as the task force prepares its final recommendation.
The AAFP will review the USPSTF’s draft recommendation statement and supporting evidence and provide comments to the task force. The Academy will release its own recommendation on the topic after the task force finalizes its guidance.