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Reuters Health Information: Screening, brief behavioral counseling can reduce unhealthy alcohol use

Screening, brief behavioral counseling can reduce unhealthy alcohol use

Last Updated: 2018-11-13

By Will Boggs MD

NEW YORK (Reuters Health) - Screening and brief behavioral-counseling interventions in primary-care settings can reduce unhealthy alcohol use in adults, according to an updated recommendation from the U.S. Preventive Services Task Force (USPSTF).

"Alcohol use is the third-leading preventable cause of death in the U.S. and contributes to more than 88,000 deaths per year," said task force member Dr. Carol Mangione from the David Geffen School of Medicine at the University of California, Los Angeles.

"In pregnancy, it also leads to birth defects and developmental problems in children," she told Reuters Health by email. "That's why it's so important that clinicians screen and treat or refer adults age 18 and older - including pregnant women - for unhealthy alcohol use and refer anyone who screens positive to one of the many effective types of counseling programs."

Since its 2013 recommendation statement, the USPSTF has replaced the term "alcohol misuse" with the term "unhealthy alcohol use," which includes behaviors ranging from risky drinking to alcohol-use disorder.

Risky use, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), exceeds the recommended limits of four drinks per day or 14 drinks per week for healthy adult men aged 21 to 64 years or three drinks per day or seven drinks per week for healthy adult women of any age and men 65 years or older.

With moderate certainty, USPSTF recommends screening for unhealthy alcohol use in primary-care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use.

Of the available screening tools, simple screening instruments offer the best accuracy for assessing unhealthy alcohol use, including the abbreviated Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and the NIAAA-recommended Single Alcohol Screening Question (SASQ).

Most behavioral counseling interventions reviewed by the USPSTF consisted of four or fewer sessions with a total contact time of two hours or less. The group was unable to identify specific intervention characteristics or components that were clearly associated with improved outcome.

There continues to be a paucity of research regarding prevention of unhealthy alcohol use in adolescents, so the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening and brief behavioral counseling interventions for alcohol use in primary-care settings in adolescents aged 12 to 17 years.

Dr. Elizabeth A. O'Connor from Kaiser Permanente Northwest, in Portland, Oregon, and colleagues detail the evidence supporting the recommendations in their updated systematic review in the November 13th issue of JAMA.

For its part, the American Academy of Pediatrics recommends screening all adolescent patients for alcohol use with a formal, validated screening tool at every health supervision visit and appropriate acute care visits and responding to screening results with the appropriate brief intervention and referral if indicated.

"Despite the recent national focus on underage drinking, there was unfortunately not enough research available for us to recommend for or against screening and brief counseling interventions for alcohol use in teens who are 12 to 17 years old," Dr. Mangione said. "This lack of evidence is a serious problem, and we are calling for more research so that we can give better guidance to clinicians on their role in preventing and mitigating the negative consequences of alcohol use in adolescents."

"It is critical to detect and address unhealthy alcohol use before more serious problems occur," she said. "We found that clinicians can really help people by screening and treating them for unhealthy alcohol use - this means simply asking questions about how often people drink and other drinking patterns. The questions take just a few minutes to answer - asking even a single question can be effective at detecting unhealthy alcohol use, which then allows people to get the help they need."

Dr. E. Jennifer Edelman from Yale School of Medicine, New Haven, Connecticut, who co-authored one of several editorials on the new recommendations, told Reuters Health by email, "There is a lot of work needed to promote implementation of these guidelines into routine clinical practice. Clinicians are challenged with many competing demands and often alcohol use is not prioritized. Rather, it is common for clinicians to focus on the consequences of alcohol use rather than the alcohol use itself."

"In addition, training is needed to equip clinicians with the tools to conduct brief counseling interventions and feel comfortable with the treatment options to address alcohol, including medications," she said. "Moreover, technology-based approaches for streamlining processes of care are needed."

"There is often concern that addressing alcohol use will offend patients, but patients are often open to discussing their alcohol use and implementing change, especially when given information that indicates that alcohol is directly impacting their health," Dr. Edelman said.

Dr. Carolyn A. McCarty of the University of Washington and Seattle Children's Research Institute, who co-authored an editorial addressing the adolescent portion of the recommendations, told Reuters Health by email, "My concern is that primary-care providers might think that since there is insufficient evidence, that they shouldn't - or don't need to - screen, but there are still compelling reasons to do so (as written in our editorial, such as providing an opportunity for prevention messaging and ensuring that the physician has a full picture on adolescent health), even as we continue to build the evidence in the field."

"The current recommendations by the American Academy of Pediatrics to screen and counsel all adolescents on alcohol use are an important component of reducing youth alcohol use," she said. "Having honest and open conversations with young people about their drinking is an important component of overall health, and is within the purview of primary care providers, similar to adults."

"I firmly believe that physicians and other primary-care providers should be engaging in conversations, including providing preventive messaging and conducting patient-centered counseling, with adolescents," Dr. McCarty said. "While more research is still needed on the impacts, the clinical value of having this information still outweighs the downsides of alcohol screening and counseling."

"In addition to the role of primary-care providers, parents and other adults in the community play important roles in protecting youth from the harmful effects of substances," she said.

"Screening and brief counseling for unhealthy drinking should be implemented universally for adults and likely for youth as well," write Dr. Angela Bazzi and Dr. Richard Saitz from Boston University School of Public Health in an editorial. "The recommendations from the USPSTF, World Health Organization, and the American Academy of Pediatrics (AAP) all support screening and brief counseling for unhealthy drinking in adults, and the AAP supports them for youth."

SOURCE:, and

JAMA 2018.

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