Primary care clinicians should screen all patients aged 18 years and older for "alcohol misuse" and provide brief behavioral counseling to patients identified as having a drinking problem, according to an updated recommendation statement from the U. S. Preventive Services Task Force.
The recommendations also put greater emphasis on screening for less risky but still hazardous patterns of alcohol use.
The most recent literature shows that the USPSTF’s suggested approach reduces these patients’ weekly alcohol consumption, promotes short- and long-term adherence to recommended drinking limits, and decreases binge drinking, according to the statement, which was published online May 14 in the Annals of Internal Medicine (Ann Intern Med. 14 May 2013 [doi:10.7326/0003-4819-159-3-201308060-00652].)
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The U.S. Preventive Services Task Force recently released a recommendation that primary care physicians should screen all patients aged 18 and older for "alcohol misuse" and provide brief counseling for patients identified as having an alcohol problem.
"Alcohol misuse" covers a spectrum of behaviors, ranging from "risky use" at the less severe end of the scale (for example, drinking more than the recommended daily, weekly, or per-occasion amounts), to "alcohol dependence" at the more severe end (for example, experiencing physical cravings and withdrawal symptoms).
The USPSTF last issued alcohol screening recommendations in 2004. The latest updates were spurred by evidence that has accumulated since 2004 showing that several brief screening tools and brief behavioral counseling interventions are effective in the primary care setting.
The new recommendations clarify the concept of alcohol misuse to include less-severe but still hazardous drinking behaviors. In fact, most of the current research concerning alcohol focuses entirely on this end of the spectrum, said Dr. Virginia A. Moyer, chair of the USPSTF and vice president for maintenance of certification and quality at the American Board of Pediatrics, and her associates.
The task force highlighted the evidence backing screening in adults, but it cautioned against extending the approach to younger populations.
The new research data show "with high certainty" that screening adults in the primary care setting for alcohol misuse and providing brief behavioral counseling interventions for those found to be engaging in risky or hazardous drinking will yield a moderate benefit – both for individual patients and for the general public.
However, the current evidence is insufficient to support this approach among adolescents. The data are lacking, of poor quality, or are conflicting, the group noted. Thus, the balance of benefits and harms cannot be determined for screening and offering behavioral counseling to adolescents in the primary care setting.
Numerous screening instruments have been developed that detect alcohol misuse among patients aged 18 years and older with good sensitivity and specificity. The three tools of choice for primary care physicians are the Alcohol Use Disorders Identification Test (AUDIT), the abbreviated AUDIT-Consumption (AUDIT-C), and a single-question screening.
The AUDIT is the most widely studied of these tools. It includes 10 questions and requires an estimated 2-5 minutes to administer. AUDIT-C includes three questions and requires 1-2 minutes to administer. Both have good sensitivity and specificity for detecting the full spectrum of alcohol misuse.
Both instruments are available from the Substance Abuse and Mental Health Services Administration at www.integration.samhsa.gov/clinical-practice/screening-tools.
The single-question screen has "adequate" sensitivity and specificity, and requires less than 1 minute to administer. For example, the National Institute on Alcohol Abuse and Alcoholism recommends simply asking patients, "How many times in the past year have you had at least five [for men] or four [for women and people older than 65 years] drinks in 1 day?"
Notably, the Cut-Down, Annoyed, Guilty, and Eye-Opener (CAGE) questionnaire has often been used by primary physicians "as a low-burden screening tool for alcohol disorders." However, that instrument "has comparatively poor sensitivity for identifying risky or hazardous drinking, particularly among older adults (only 14%-39%) and pregnant women (38%-49%)," Dr. Moyer and her associates said.
The optimal interval for rescreening patients cannot be determined yet, because the evidence is lacking, they added.
There are several behavioral counseling interventions that can be used by the primary care physician for any adult patients who test positive on these screens. Interventions often include cognitive behavioral techniques such as keeping drinking diaries and formulating action plans. They can be administered face-to-face or via written self-help materials, computer- or Web-based programs, or telephone counseling.
The most effective approaches use brief, multiple contacts – a series of interactions with the patient that last from 6 to 15 minutes each. Very brief (less than 5 minutes) single or multiple contacts appear to be less effective, as do extended (longer than 15 minutes) single or multiple contacts.