Screening and Behavioral Counseling Interventions in Primary Care To Reduce Alcohol Misuse: Recommendation Statement

Summary of the Recommendations The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling interventions to reduce alcohol misuse (see Clinical Considerations) by adults, including pregnant women, in primary care settings. This is a grade B recommendation. (See Appendix Table 1 for a description of the USPSTF classification of recommendations.) The USPSTF found good evidence that screening in primary care settings can accurately identify patients whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence, but place them at risk for increased morbidity and mortality, and good evidence that brief behavioral counseling interventions with follow-up produce small to moderate reductions in alcohol consumption that are sustained over 6- to 12-month periods or longer. (See Appendix Table 2 for a description of the USPSTF classification of levels of evidence.) The USPSTF found some evidence that interventions lead to positive health outcomes 4 or more years postintervention, but found limited evidence that screening and behavioral counseling reduce alcohol-related morbidity. The evidence on the effectiveness of counseling to reduce alcohol consumption during pregnancy is limited; however, studies in the general adult population show that behavioral counseling interventions are effective among women of childbearing age. The USPSTF concluded that the benefits of behavioral counseling interventions to reduce alcohol misuse by adults outweigh any potential harms. Appendix Table 1. U.S. Preventive Services Task Force Recommendations and Ratings Appendix Table 2. U.S. Preventive Services Task Force Strength of Overall Evidence The USPSTF concludes that the evidence is insufficient to recommend for or against screening and behavioral counseling interventions to prevent or reduce alcohol misuse by adolescents in primary care settings. This is a grade I recommendation. The USPSTF found limited evidence evaluating the effectiveness of screening and behavioral counseling interventions in primary care settings to prevent or reduce alcohol misuse by adolescents. The USPSTF concluded that the evidence is insufficient to assess the potential benefits and harms of screening and behavioral counseling interventions in this population. Clinical Considerations Alcohol misuse includes risky/hazardous and harmful drinking that places individuals at risk for future problems. Risky or hazardous drinking has been defined in the United States as more than 7 drinks per week or more than 3 drinks per occasion for women and more than 14 drinks per week or more than 4 drinks per occasion for men. Harmful drinking describes persons who are currently experiencing physical, social, or psychological harm from alcohol use but do not meet criteria for dependence (1, 2). Alcohol abuse and dependence are associated with repeated, negative physical, psychological, and social effects from alcohol (3). The USPSTF did not evaluate the effectiveness of interventions for alcohol dependence because the benefits of these interventions are well established and referral or specialty treatment is recommended for those meeting the diagnostic criteria for dependence. Light to moderate alcohol consumption in middle-aged or older adults has been associated with some health benefits, such as reduced risk for coronary heart disease (4). Moderate drinking has been defined as 2 standard drinks (for example, 12 ounces of beer) or less per day for men and 1 drink or less per day for women and persons older than 65 years of age (5), but recent data suggest comparable benefits from as little as 1 drink 3 to 4 times a week (6). The Alcohol Use Disorders Identification Test (AUDIT) is the most studied screening tool for detecting alcohol-related problems in primary care settings. It is sensitive for detecting alcohol misuse and abuse or dependence, and can be used alone or embedded in broader health risk or lifestyle assessments (7, 8). The 4-item CAGE (feeling the need to Cut down, Annoyed by criticism, Guilty about drinking, and need for an Eye-opener in the morning) is the most popular screening test for detecting alcohol abuse or dependence in primary care (9). The TWEAK, a 5-item scale, and the T-ACE are designed to screen pregnant women for alcohol misuse. They detect lower levels of alcohol consumption that may pose risks during pregnancy (10). Clinicians can choose screening strategies that are appropriate for their clinical population and setting (8, 11-14). Screening tools are available at the National Institute on Alcohol Abuse and Alcoholism Web site: www.niaaa.nih.gov/publications/instable.htm. Effective interventions to reduce alcohol misuse include an initial counseling session of about 15 minutes, feedback, advice, and goal-setting. Most also include further assistance and follow-up. Multicontact interventions for patients ranging widely in age (12 to 75 years) are shown to reduce mean alcohol consumption by 3 to 9 drinks per week, with effects lasting up to 6 to 12 months after the intervention. They can be delivered wholly or in part in the primary care setting, and by 1 or more members of the health care team, including physician and nonphysician practitioners. Resources that help clinicians deliver effective interventions include brief provider training or access to specially trained primary care practitioners or health educators, and the presence of office-level systems supports (prompts, reminders, counseling algorithms, and patient education materials). Primary care screening and behavioral counseling interventions for alcohol misuse can be described with reference to the 5 A's behavioral counseling framework: assess alcohol consumption with a brief screening tool followed by clinical assessment as needed; advise patients to reduce alcohol consumption to moderate levels; agree on individual goals for reducing alcohol use or abstinence (if indicated); assist patients with acquiring the motivations, self-help skills, or supports needed for behavior change; and arrange follow-up support and repeated counseling, including referring dependent drinkers for specialty treatment (15). Common practices that complement this framework include motivational interviewing (16), the 5 R's used to treat tobacco use (17), and assessing readiness to change (18). The optimal interval for screening and intervention is unknown. Patients with past alcohol problems, young adults, and other high-risk groups (such as smokers) may benefit most from frequent screening. All pregnant women and women contemplating pregnancy should be informed of the harmful effects of alcohol on the fetus. Safe levels of alcohol consumption during pregnancy are not known; therefore, pregnant women are advised to abstain from drinking alcohol. More research into the efficacy of primary care screening and behavioral intervention for alcohol misuse among pregnant women is needed. The benefits of behavioral intervention for preventing or reducing alcohol misuse in adolescents are not known. The CRAFFT questionnaire was recently validated for screening adolescents for substance abuse in the primary care setting (19). The benefits of screening this population will need to be evaluated as more effective interventions become available in the primary care setting. The brief review of the evidence that is normally included in USPSTF recommendations is available in the complete recommendation statement on the USPSTF Web site (www.preventiveservices.ahrq.gov). Recommendations of Others Professional groups such as the American Medical Association (AMA) (www.ama-assn.org/ama/pub/article/2036-2393.html), the American Society of Addiction Medicine (www.asam.org/ppol/screen.htm), and the Canadian Task Force on Preventive Health Care (ctfphc.org/) recommend routine screening for alcohol misuse in primary care and brief counseling interventions for individuals who screen positive. The American College of Obstetricians and Gynecologists (acog.org/) and the American Academy of Pediatrics (AAP) (aappolicy.aappublications.org/policy_statement/index.dtl) recommend counseling all women who are pregnant or are planning pregnancy about the harmful effects of drinking to the fetus and that abstinence is the safest policy. The AAP and the AMA guidelines for Adolescent Preventive Services (www.ama-assn.org/ama/upload/mm/39/gapsmono.pdf) recommend that clinicians routinely screen children and adolescents for alcohol use and advise patients to abstain from alcohol. The AAP also recommends that physicians discuss the hazards of alcohol and other drug use with parents during routine risk behavior assessment (aappolicy.aappublications.org/cgi/content/abstract/pediatrics;108/1/185?fulltext=alcohol+drug+abuse&searchid=QID_NOT_SET/content/full/pediatrics/;108/1/185).