November 15, 2018

All adults should be screened for 'unhealthy' drinking, USPSTF says. Here's what that means.

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    What's considered 'unhealthy?'

    "Unhealthy alcohol use" for adult men is more than four drinks in a single day or more than 14 drinks in a week for men aged 21 to 64, or more than three drinks in a single day or seven drinks in a week for women of any age and men above 64, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

    For pregnant women, consumption of any alcoholic beverage is considered unhealthy, as alcohol can cause birth defects. 

    USPSTF recommends screening, counseling for adults

    USPSTF based the latest recommendation on a systematic review of existing evidence that examined the effectiveness of alcohol use screening to reduce unhealthy drinking and prevent related morbidity, mortality, and unhealthy behaviors. The evidence review also addressed the effectiveness of different screening approaches and counseling interventions as well as the harms of screening approaches and behavioral interventions.

    Based on that data, USPSTF said primary care clinicians should screen all adults, including pregnant women for unhealthy alcohol use. USPSTF said there is adequate evidence that screening instruments can detect unhealthy alcohol use with "acceptable sensitivity and specificity" in adults older than 18, including pregnant women.

    According to USPSTF, the most accurate screening assessments include the abbreviated Alcohol Use Disorders Identification Test-Consumption and the NIAAA-recommended Single Alcohol Screen Question. Meanwhile, USPSTF said a separate screening approached called "Cut down, Annoyed, Guilty, Eye-opener" is not considered an accurate screening tool for this recommendation, as it intends to detect alcohol dependence only, not the "fully spectrum of unhealthy alcohol use," USPSTF said.

    If unhealthy alcohol use is detected, clinicians should provide behavioral counseling inventions, which USPSTF said are associated with lowering the risk a patient will exceed recommended drinking limits and heavy use episodes in six-month and 12-month follow-up.

    The recommendation carries a B grade, which means "[t]here is high certainty that the net benefit [of the intervention] is moderate or there is moderate certainty that the net benefit is moderate to substantial."

    USPSTF finds insufficient evidence for screening adolescents

    At the same time, USPSTF in a separate statement said there was insufficient evidence to support alcohol screening in adolescents.  

    However, while USPSTF did not endorse screening adolescents, NIAAA and American Academy of Pediatrics recommend a screening tool called "Car, Relax, Alone, Forget, Family, Friends, Trouble" for detecting risk substance use in adolescents. USPSTF noted that NIAAA recommends asking patients about their alcohol use as well as friends.

     Alcohol screening often overlooked

    In an accompanying editorial, Angela Bazzi and Richard Saitz, both of Boston University School of Public Health, write that the recommendations for adults are in line with USPSTF's 1996 recommendations. 

    But more than two decades later, "implementation of screening and brief intervention still remains quite low," Bazzi and Saitz write. "For example, in the United States, one in six patients reports having discussed alcohol with their physician; rates in Europe are similarly low," Bazzi and Saitz explain.

    Bazzi and Saitz suggest the low screening rates could be attributed to "challenges related to implementation, perceptions of alcohol use, and clinicians' perceptions of their roles." They note that even when physicians perform the screenings, they "infrequently use" questionnaires that are validated.

    Bazzi and Saitz conclude, "Patients expect a drinking checkup, and it is time for clinicians, with support, to provide it" (Bazzi/Saitz,  JAMA, 11/13; Phillips, Medscape, 11/13; Scutti, CNN, 11/3; McCarty et al., JAMA Pediatrics, 11/13; USPSTF, "Grade Definitions," accessed 11/14).

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