Introduction (original) (raw)

Alcohol misuse, which includes the full spectrum from drinking above recommended limits (i.e., risky/hazardous drinking) to alcohol dependence,1-3 is associated with numerous health and social problems and more than 85,000 deaths per year in the United States,1, 4 with an estimated annual cost to society of more than $220 billion.5, 6 Alcohol misuse is estimated to be the third leading cause of preventable mortality in the United States, following tobacco use and overweight.7 Alcohol misuse contributes to a variety of conditions, including hypertension, cirrhosis, gastritis and gastric ulcers, pancreatitis, breast cancer, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, and suicide.8, 9 Excessive alcohol consumption is a major factor in injury and violence.10 Acute alcohol-related harm can be the result of fires, drowning, falls, homicide, suicide, motor vehicle crashes, child maltreatment, and pedestrian injuries.11

Risky/hazardous drinking and alcohol-related disorders (i.e., alcohol abuse and dependence) are a widespread public health problem in the United States. In 2007, the number of alcoholic liver disease deaths was 14,406 and the number of alcohol-induced deaths, excluding accidents and homicides, was 23,199.7 In 2008, more than 11,000 people were killed in alcohol-impaired driving crashes.12 These fatalities accounted for 32 percent of all motor vehicle traffic fatalities in the United States. Risky/hazardous or harmful drinking that goes unrecognized can further complicate the assessment and treatment of medical and psychiatric conditions.9

Definitions of the spectrum of alcohol misuse (i.e., unhealthy alcohol use3) continue to evolve. For the purposes of this report we use the definitions described in Table 1.

Table 1. Definitions of the spectrum of alcohol misuse.

Table 1

Definitions of the spectrum of alcohol misuse.

Though estimating the prevalence of alcohol misuse is challenging, it has been estimated that about 30 percent of the U.S. population is affected, with the majority of these individuals engaging in what is considered risky drinking.3 Alcohol dependence has lifetime prevalence rates on the order of 17 percent for men and 8 percent for women;13 prevalence of current dependence (within the last 12 months and as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV]) is approximately 4 percent in the general adult population.14

Currently, an estimated 50 percent of adults 18 years of age or older are regular drinkers.15 About 18 percent of adolescent boys and 14 percent of adolescent girls from 12 to 17 years of age reported drinking before age 13.7 Although often underreported, alcohol use remains common among older people. An estimated 6 percent of older adults are considered to be heavy users of alcohol.16 Lastly, in a recent survey 11.8 percent of pregnant women in the United States reported recent use of alcohol.17

Older studies report a range of risky drinkers (4% to 29%) across multiple primary care populations, with prevalence estimates of 0.3 to 10.0 percent for harmful drinkers and 2.0 to 9.0 percent for alcohol dependence.18 More recent data from the American Academy of Family Physicians National Research Network reveal that 21.3 percent of primary care patients reported risky/hazardous drinking (based on the three quantity and frequency questions from the AUDIT-C).19 Approximately one in five of those who screen positive for unhealthy alcohol use in primary care will have alcohol dependence (four in five will not).17, 20 Rates of alcohol-use disorders among medical outpatients are similar to those seen in the general population and are generally higher in males and younger people of all races/ethnicities.18, 21

Primary care clinicians commonly see patients with a range of alcohol-related risks and problems. In Wisconsin, about 20 percent of primary care patients were found to be risky drinkers based on National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines.20 Across multiple primary care populations, 4 percent to 29 percent are risky drinkers, 0.3 percent to 10 percent are harmful drinkers, and 2 percent to 9 percent exhibit alcohol dependence.18 Prevalence of these forms of alcohol misuse generally is higher in males and younger people of all races and ethnicities.21

Several agencies have established guidelines for recommended levels of alcohol consumption that are considered to be safe. These guidelines do not apply to people (such as adolescents, pregnant women, and those with alcohol dependence or medical conditions or medication use) for whom alcohol intake is contraindicated, or to circumstances (driving) in which no consumption is considered safe. The NIAAA has proposed epidemiologically based alcohol-use guidelines to limit risks for short- and long-term drinking-related consequences by establishing age- and sex-specific recommended consumption thresholds.25 Maximum recommended consumption is 3 or fewer standard drinks per day (7 per week) for adult women and for anyone older than 65 years of age, and 4 or fewer standard drinks per day (14 per week) for adult men. A standard drink is defined as one 12-ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits.26, 27

Screening and Behavioral Counseling

Physicians who provide ongoing care can assist patients who have current problems, or who are at risk for problems, through effective identification (screening and screening-related assessment), office-based interventions, and referrals to specialty services as needed.28 The American Society of Addiction Medicine recommends that the services of primary care physicians and other primary health care providers include, at a minimum, the provision of the following four elements of care:29 (1) assessment of the nature and extent of alcohol, nicotine, and other drug use by patients, with consistency of data collection and documentation akin to the consistency of assessment and documentation of vital signs; (2) routine screening for the presence of alcohol, nicotine, or other drug use problems in patients, as well as screening for risk factors for development of alcohol, nicotine, and other drug dependence; (3) appropriate intervention by the primary care provider; and (4) ongoing general medical care services to people who manifest alcohol, nicotine, or other drug problems, including dependence.

Several screening questionnaires can be used to identify alcohol misuse. The most commonly studied instruments include the Alcohol Use Disorders Identification Test (AUDIT) and its abbreviated versions (e.g., the AUDIT-C), the CAGE questionnaire (Cut-down, Annoyed, Guilty, Eye-opener), the Michigan Alcoholism Screening Test (MAST), and versions of the single-question screen. Greater description of these and other instruments is provided in Key Question 2 and related appendixes.

Behavioral interventions and patient education are often used for patients who engage in less severe alcohol misuse (i.e., risky/hazardous drinking).1 Brief interventions generally aim to moderate a patient's alcohol consumption to sensible levels and to eliminate risky drinking practices, rather than to insist on complete abstinence. There is ongoing debate about the elements of a brief intervention.30 In general, behavioral counseling interventions include the range of personal counseling and related behavior-change interventions that are employed in primary care to help patients change health-related behaviors.31 Counseling here denotes a cooperative mode of work demanding active participation from both patient and clinician that aims to facilitate the patient's independent initiative.31 The Substance Abuse and Mental Health Services Administration (SAMHSA) defines brief intervention as “a single session or multiple sessions of motivational discussion focused on increasing insight and awareness regarding substance use and motivation toward behavioral change.”32 These interventions range from very brief interventions within a primary care visit to multicontact interventions that entail multiple, often more lengthy, visits and nonvisit contacts over an extended period.1 Brief alcohol interventions can include advice, feedback, motivational interviews of varying length and number, or cognitive behavioral strategies (e.g., self-completed action plans, written health education or self-help materials, drinking diaries, problem-solving exercises to complete at home). Interventions may be delivered via face-to-face sessions, written self-help materials, computer, or telephone counseling.

The assumption underlying brief behavioral counseling interventions in primary care is that, for identified risky drinkers, reducing overall alcohol consumption or adopting safer drinking patterns (that is, fewer drinks per occasion and not drinking before driving) will reduce the risk for medical, social, and psychological problems.33 Cross-sectional and cohort studies have consistently related high average alcohol consumption to short- or long-term health consequences.27, 34 A meta-analysis of studies examining the association between all-cause mortality and average alcohol consumption found that men averaging at least four drinks per day and women averaging two or more drinks per day experienced significantly increased mortality relative to nondrinkers.35 Studies also relate heavy per-occasion alcohol use (“binge drinking”) to acute injury risks and alcohol-related life problems.27, 34 Injury rates are higher for binge drinkers who consume five or more drinks on one occasion as infrequently as three to six times per year, even when average intake is not excessive.36

Prior U.S. Preventive Services Task Force Recommendations

In 2004, the U.S. Preventive Services Task Force (USPSTF) developed recommendations for screening and behavioral counseling interventions in primary care to reduce alcohol misuse.37 The summary of the recommendations states as follows:

The USPSTF made a distinction between screening and screening-related assessment. Screening involves identifying patients with probable risky alcohol use, whereas screening-related assessment entails confirming screening results and distinguishing patients suitable for brief interventions from those needing specialty care referral.

In the report developed for the USPSTF, it was generally accepted that less severe alcohol problems (e.g., risky/hazardous drinking) are appropriate for brief interventions in primary care, whereas more severe problems, particularly alcohol abuse and dependence, may require specialty addiction treatment.1, 37 However, specialty treatment services may be in short supply, and some people may not be willing to follow up with specialty treatment services. Consequently, primary care physicians may sometimes provide the only care that people with alcohol abuse or dependence receive.

Current Practice

The NIAAA and others encourage physicians to identify patients with alcohol-related risks or problems and to provide office-based brief interventions or referrals as needed.25, 28, 38 In everyday practice, screening and screening-related assessment procedures are necessary to identify those who misuse alcohol in order to offer appropriate interventions.39, 40

Even so, few primary care clinicians use recommended screening protocols or offer screening and interventions, and rates of intervening for alcohol misuse remain low.40 One study of primary care physicians found that although most (88%) reported asking their patients about alcohol use, only 13 percent used standardized screening instruments.40 Another study found that patients with alcohol dependence received the recommended quality of care, including assessment and referral to treatment, only about 10 percent of the time.41 Less than a quarter of people with alcohol-related disorders ever seek help for these conditions; higher proportions of women than men seek help, despite the higher prevalence of alcohol-related disorders among men.9 Most patients who misuse alcohol receive care from their general practitioner or primary care provider, where they represent as much as one-fifth of patients seen, a proportion similar to the proportions seen for diabetes and hypertension.9, 18

In a recent clinician's guide to the NIAAA guidelines,42 the authors explain that many primary care physicians are familiar with counseling at-risk drinkers but choose to refer most patients to specialized rehabilitation programs. These programs may not be appropriate for those with risky alcohol use who do not meet the DSM-IV-TR criteria for abuse or dependence. In addition, most patients with a positive screening result for a drinking problem are unlikely to accept referrals for alcohol-related counseling.43 Even if patients accept a referral and complete a rehabilitation program, only about one third will respond to treatment.44

Scope and Key Questions

This topic was selected by the USPSTF (through their topic prioritization process), which aims to update its recommendations every 5 years in accordance with criteria for inclusion in the National Guideline Clearinghouse. The most recent USPSTF recommendations for screening and behavioral counseling interventions in primary care to reduce risky/harmful alcohol use were issued in 2004.37 In this new review, we used similar Key Questions (KQs) to those in the earlier systematic review that informed the USPSTF recommendations, titled Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use.1 In addition, the scope of this report has been expanded to allow the inclusion of screening and behavioral interventions for the full spectrum of alcohol misuse, expanding the review to include subjects with alcohol abuse and dependence, as long as subjects were identified by screening in a primary care or primary care-like setting. We also added “referral” as an intervention of interest and changed the title to reflect this addition. Because of the changes in scope and revisions to the KQs, we did not simply evaluate new literature since the previous report (i.e., an update of the previous document), but instead, we newly evaluated all of the literature dating back to 1985 that addressed our KQs.

The main objective of this report is to conduct a systematic review of the effectiveness of screening followed by behavioral counseling, with or without referral, for alcohol misuse in primary care settings. In this review, we address the following KQs: