Alcohol Misuse - Screening and Behavioral Counseling Interventions in Primary Care-Adult

Alcohol Misuse - Screening and Behavioral Counseling Interventions in Primary Care-Adult

Alcohol Misuse - Screening and Behavioral Counseling Interventions in Primary Care

Summary of Recommendations and Evidence

Population Recommendation Grade
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Adults aged 18 and older

The USPSTF recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse

 B
Adolescents (under 18 years of age)

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening and behavioral counseling interventions in primary care settings to reduce alcohol misuse in adolescents.

 I

Importance

The USPSTF uses the term “alcohol misuse” to define a spectrum of behaviors, including risky or hazardous alcohol use (for example, harmful alcohol use and alcohol abuse or dependence). Risky or hazardous alcohol use means drinking more than the recommended daily, weekly, or per-occasion amounts resulting in increased risk for health consequences. For example, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the U.S. Department of Agriculture define “risky use” as consuming more than 4 drinks on any day or 14 drinks per week for men, or more than 3 drinks on any day or 7 drinks per week for women (as well as any level of consumption under certain circumstances)1, 2. “Harmful alcohol use” (defined by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision) is a pattern of drinking that causes damage to physical or mental health3.

“Alcohol abuse” (defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) is drinking that leads an individual to recurrently fail in major home, work, or school responsibilities; use alcohol in physically hazardous situations (such as while operating heavy machinery); or have alcohol-related legal or social problems4. “Alcohol dependence” (or alcoholism) (defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) includes physical cravings and withdrawal symptoms, frequent consumption of alcohol in larger amounts than intended over longer periods, and a need for markedly increased amounts of alcohol to achieve intoxication4.

An estimated 30% of the U.S. population is affected by alcohol misuse, and most of these persons engage in risky use. More than 85,000 deaths per year are attributable to alcohol misuse; it is the estimated third leading cause of preventable deaths in the United States5, 6.

Detection

The USPSTF found adequate evidence that numerous screening instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity.

Benefits of Detection and Behavioral Counseling Interventions

The USPSTF found adequate evidence that brief behavioral counseling interventions are effective in reducing heavy drinking episodes in adults engaging in risky or hazardous drinking. These interventions also reduce weekly alcohol consumption rates and increase adherence to recommended drinking limits. Direct evidence about the effectiveness of brief behavioral counseling interventions in pregnant women engaging in alcohol use is more limited. However, studies in the general adult population show that such interventions reduce alcohol consumption and increase adherence to recommended drinking limits among women of childbearing age.

The USPSTF found insufficient evidence on the effect of screening for alcohol misuse and brief behavioral counseling interventions on outcomes in adolescents.

Harms of Detection and Behavioral Counseling Interventions

There are minimal data to assess the magnitude of harms of screening for alcohol misuse or of consequent brief behavioral counseling interventions in any population. However, no studies have identified direct evidence of harms. Thus, given the noninvasive nature of the screening process and behavioral counseling interventions, the related harms are probably small to none.

USPSTF Assessment

The USPSTF concludes with moderate certainty that there is a moderate net benefit to screening for alcohol misuse and brief behavioral counseling interventions in the primary care setting for adults aged 18 years or older.

The evidence on screening for alcohol misuse and brief behavioral counseling interventions in the primary care setting for adolescents is insufficient, and the balance of benefits and harms cannot be determined.

Patient Population Under Consideration

The B recommendation applies to adults aged 18 years and older, and the I statement applies to adolescents aged 12 to 17 years. Although pregnant women are included, this recommendation is related to decreasing risky or hazardous drinking, not to complete abstinence, which is recommended for all pregnant women. These recommendations do not apply to persons who are actively seeking evaluation or treatment for alcohol misuse.

Screening Tests

The USPSTF considers 3 tools as the instruments of choice for screening for alcohol misuse in the primary care setting: the Alcohol Use Disorders Identification Test (AUDIT), the abbreviated AUDIT-Consumption (AUDIT-C), and single-question screening (for example, the NIAAA recommends asking, “How many times in the past year have you had 5 [for men] or 4 [for women and all adults older than 65 years] or more drinks in a day?”).

Of available screening tools, AUDIT is the most widely studied for detecting alcohol misuse in primary care settings; both AUDIT and the abbreviated AUDIT-C have good sensitivity and specificity for detecting the full spectrum of alcohol misuse across multiple populations. AUDIT comprises 10 questions and requires approximately 2 to 5 minutes to administer; AUDIT-C comprises 3 questions and takes 1 to 2 minutes to complete. Single-question screening also has adequate sensitivity and specificity across the alcohol-misuse spectrum and requires less than 1 minute to administer.

Behavioral Counseling Interventions

Behavioral counseling interventions for alcohol misuse vary in their specific components, administration, length, and number of interactions. They may include cognitive behavioral strategies, such as action plans, drinking diaries, stress management, or problem solving. Interventions may be delivered by face-to-face sessions, written self-help materials, computer- or Web-based programs, or telephone counseling. For the purposes of this recommendation statement, the USPSTF uses the following definitions of intervention intensity: very brief single contact (≤5 minutes), brief single contact (6 to 15 minutes), brief multicontact (each contact is 6 to 15 minutes), and extended multicontact (≥1 contact, each >15 minutes). Brief multicontact behavioral counseling seems to have the best evidence of effectiveness; very brief behavioral counseling has limited effect5, 6.

The USPSTF found that counseling interventions in the primary care setting can positively affect unhealthy drinking behaviors in adults engaging in risky or hazardous drinking. Positive outcomes include reducing weekly alcohol consumption and long-term adherence to recommended drinking limits. Because brief behavioral counseling interventions decrease the proportion of persons who engage in episodes of heavy drinking (which results in high blood alcohol concentration [BAC]), indirect evidence supports the effect of screening and brief behavioral counseling interventions on important health outcomes, such as the probability of traumatic injury or death, especially that related to motor vehicles.

Although screening detects persons along the entire spectrum of alcohol misuse, trials of behavioral counseling interventions in primary care settings largely focused on risky or hazardous drinking rather than alcohol abuse or dependence. Limited evidence suggests that brief behavioral counseling interventions are generally ineffective as singular treatments for alcohol abuse or dependence. The USPSTF did not formally evaluate other interventions (such as pharmacotherapy or outpatient treatment programs) for alcohol abuse or dependence, but the benefits of specialty treatment are well-established and recommended for persons meeting the diagnostic criteria for alcohol dependence.

Screening Intervals

Evidence is lacking to determine the optimal interval for screening for alcohol misuse in adults.

Suggestions for Practice Regarding the I Statement

In deciding whether to screen adolescents for alcohol misuse and provide behavioral counseling interventions, primary care providers should consider the following factors.

Potential Preventable Burden

In 2010, approximately 14% of adolescents in the 8th grade and 41% in the 12th grade reported using alcohol at least once within the past 30 days; 7% and 23%, respectively, reported consuming at least 5 or more drinks on a single occasion (an episode of heavy use) within the previous 2 weeks7. Motor vehicle crashes are the leading cause of death for adolescents8; according to the Substance Abuse and Mental Health Services Administration, about 4% of 16-year-olds and 9% of 17-year-olds in 2009 drove under the influence of alcohol at least once during the previous year9. Thirty-seven percent of traffic deaths among youth aged 16 to 20 years involve alcohol, and these deaths frequently involve alcohol-impaired drivers with lower BACs than other age groups10.

Costs

Behavioral counseling interventions are associated with a time commitment ranging from 5 minutes to 2 hours, spread over multiple contacts. There are potential financial costs for parents and caregivers from lost work hours and travel to and from the provider.

Potential Harms

Potential harms associated with screening for alcohol misuse include anxiety, stigma or labeling, and interference with the clinician-patient relationship. Although evidence is very limited, no direct harms were identified for any population in available studies.

Current Practice

Research suggests that although a majority of pediatricians and family practice clinicians report providing some alcohol prevention services to adolescent patients, they do not universally or consistently screen and counsel for alcohol misuse11. Barriers include a perceived lack of time, familiarity with screening tools, training in managing positive results, and available treatment resources12.

Useful Resources

The AUDIT and AUDIT-C screening instruments for alcohol misuse are available from the Substance Abuse and Mental Health Services Administration-Health Resources and Services Administration Center for Integrated Health Solutions (www.integration.samhsa.gov/clinical-practice/screening-toolsThis link goes offsite. Click to read the external link disclaimer). Further details about the single-question screening method, as well as resources on primary care–feasible behavioral interventions, are available from the NIAAA (http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdfThis link goes offsite. Click to read the external link disclaimer).

The Community Preventive Services Task Force recommends electronic screening and brief intervention to reduce excessive alcohol consumption. Electronic screening and brief intervention uses electronic devices (for example, computers, telephones, or mobile devices) to facilitate screening for excessive drinking and delivering a brief intervention that provides personalized feedback about the risks and consequences of excessive drinking. Delivery of personalized feedback can range from fully automated (computer-based) to interactive (provided by a person over the telephone). At least one part of the brief intervention must be delivered by an electronic device. Electronic screening and brief intervention can be delivered in various settings, such as health care systems, universities, or communities. The Community Preventive Services Task Force found limited information on the effectiveness of electronic screening and brief intervention among adolescents.

The Community Preventive Services Task Force has also evaluated public health interventions (those that occur outside of the clinical practice setting) to prevent excessive alcohol consumption. It recommends instituting liability laws for establishments that sell or serve alcohol, increasing taxes on alcohol, maintaining limits on days and hours of the sale of alcohol, and regulating alcohol outlet density in communities as effective in preventing or reducing alcohol-related harms. It also recommends enhanced enforcement of laws prohibiting the sale of alcohol to minors. More information about the Community Preventive Services Task Force's recommendations on alcohol misuse is available at www.thecommunityguide.org/alcohol/index.htmlThis link goes offsite. Click to read the external link disclaimer.

The Cochrane Collaboration has performed 2 systematic reviews to evaluate the effects of universal school- and family-based prevention programs to prevent or reduce alcohol misuse in young people. Although not entirely consistent across studies, evidence generally supported the effectiveness of certain school-based psychosocial and developmental programs, such as the Life Skills Training Program, the Unplugged Program, and the Good Behavior Game13. Similarly, evidence generally supported small but positive effects from family-based interventions in preventing alcohol misuse in young people14.

The USPSTF has made recommendations on screening for and interventions to decrease the unhealthy use of other substances, including illicit drugs and tobacco. More information can be found atwww.uspreventiveservicetaskforce.org.