All Adults Should be Screened for Alcohol Misuse
04/05/04 Portland, Ore.
Analysis by Oregon researchers prompts U.S. Preventive Services Task Force to recommend alcohol screening for all adults, including pregnant women
All adults, including pregnant women, should be screened by their physicians for alcohol misuse and referred for counseling if necessary, according to an updated recommendation issued today by the U.S. Preventive Services Task Force.
The Task Force, an independent panel of experts sponsored by the Agency for Healthcare Research and Quality, based its conclusion on a report from a team led by Evelyn P. Whitlock, M.D., M.P.H., of the Oregon Evidence-Based Practice Center, a consortium of clinicians and researchers from Oregon Health & Science University, Kaiser Permanente's Center for Health Research and the Portland Veterans Affairs Medical Center. The findings are published in the April 6 issue of the Annals of Internal Medicine.
Women who drink more than seven drinks a week or more than three drinks per occasion, and men who drink more than 14 drinks a week or more than four drinks per occasion are considered to be risky or hazardous drinkers, according to the Task Force. Alcohol misuse includes risky drinking and harmful drinking. Harmful drinking is defined as behavior exhibited by individuals who are experiencing physical, social or psychological harm from alcohol, but who do not meet the criteria for alcohol dependence as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
"Alcohol misuse, tobacco use, poor diet and physical inactivity accounted for almost 40 percent of deaths in the United States in 2000," said Whitlock, senior investigator at Kaiser Permanente's Center for Health Research. "We found that the research supporting behavioral interventions delivered in primary care to reduce risky and harmful alcohol use is second in quality and relevance only to that for tobacco interventions. The good news is that brief, multi-contact interventions to reduce alcohol misuse among adults works equally well for women and men, and for adults older than 65 as well as middle-aged adults."
Alcohol misuse is strongly associated with more than 100,000 preventable deaths each year and is linked to health problems, anxiety and depression, tobacco use, disability, motor vehicle crashes, accidents, injury, social disruption, and violence. Higher levels of alcohol consumption are linked to increased cirrhosis, diseases of the central nervous system, high blood pressure, and cancers of the head and neck, digestive tract, liver, and breast. Excessive alcohol use during pregnancy can cause fetal alcohol syndrome, which can cause growth retardation, facial deformities, and central nervous system dysfunction. In the United States, alcohol abuse costs nearly $185 billion annually.
"Dr. Whitlock's analysis is a breakthrough on two fronts," said Mark Helfand, M.D., M.P.H., director of the Oregon Evidence-Based Practice Center. "First, thanks to recent behavior change research, counseling to change dangerous drinking behavior met the same high standard of proof we apply to evaluate screening tests. Second, by careful attention to the details of successful counseling, Dr. Whitlock enabled the USPSTF to recommend specific approaches to counseling that primary care clinicians can learn and apply in their practice with confidence."
According to the researchers, as many as 25 percent of all patients seen by primary care clinicians in some settings may be risky drinkers. Several clinical screening tools for alcohol-related problems currently are available for adults and pregnant women and can be found online at the National Institute on Alcohol Abuse and Alcoholism's Web site, http://www.niaaa.nih.gov/publications/instable.htm
According to the Task Force, effective counseling sessions for adults identified as risky drinkers should consist of:
A 15-minute initial session that includes advice to reduce current drinking.
Feedback about current drinking patterns.
Explicit goal setting, usually for moderation.
Assistance in achieving the goal.
Follow-up through telephone calls, repeat visits and repeat monitoring.
Counseling sessions can be delivered in the primary care setting by one or more members of the health care team, including physicians and other health practitioners, as well as health educators and others trained in alcohol-specific counseling methods. Primary care office-level system supports such as prompts, reminders, step-by-step counseling procedures and patient education materials are helpful, the Task Force noted.
In a separate finding, the Task Force concluded there isn't enough rigorous scientific evidence yet to recommend for or against screening and counseling interventions in primary care settings to curb alcohol misuse by adolescents. Although young adults aged 18 to 25 have the highest rates of binge and heavy drinking, the Task Force found few adequate-quality studies on interventions aimed at adolescents in the primary care setting to reduce alcohol misuse. More research is needed, they noted.
The Task Force, sponsored by the Agency for Healthcare Research and Quality, is the leading independent panel of private-sector experts in prevention and primary care and conducts rigorous, impartial assessments of the scientific evidence for a broad range of preventive services. Its recommendations are considered the gold standard for clinical preventive services.
Task Force recommendations and materials for clinicians are available on the Web at http://www.ahrq.gov/clinic/uspstf/uspsdrin.htm.