Alcohol screening fulfills important duty to patients

What advice do you have on how to ask patients about their levels of alcohol use?

Reply:

What a lost opportunity! What may be the most blatant oversight in routine medical practice today is that while hundreds of thousands of patients enter health care settings every day with problems due to their overuse of alcohol, their physicians rarely ask them about drinking.

With alcohol abuse and dependence affecting 17.6 million adults in America, one would ask how this is reflected in medical settings.

Research shows that 7% to 20% of outpatients, 30% to 40% of patients in emergency departments and upwards of 50% of patients with trauma have significant alcohol problems. Despite these findings, most patients are not asked about alcohol problems, and even fewer receive professional advice about their drinking. In fact, in a recent study that examined the quality of health care in the United States for 25 health conditions, alcohol care ranked last.

Why is this? It may be that the stigma associated with problem drinking affects both the willingness of patients to seek medical advice and the willingness of physicians to address this public health problem head-on.

Given the medical complexities of the problem, the profound effects of avoiding it, the ease of clinical intervention, and evidence supporting positive outcomes, it seems to me that screening and brief intervention for alcohol problems is as much an ethical concern as a clinical responsibility for all physicians.

Screening and brief intervention for alcohol problems are neither complex nor time consuming to perform with several validated approaches. For example, one approach that is widely used for screening is consumption questions that focus on frequency, quantity and bingeing.

The National Institute on Alcohol Abuse and Alcoholism's recently published clinical guideline, "Helping Patients Who Drink Too Much," is available in pdf form on NIAA's Web site (link). It demonstrates that a single question can screen for risky drinking. Ask: "How many times during the past year have you had five or more drinks a day (for men) or four or more in a day (for women)?" Any positive response deserves further attention.

General guidelines state that healthy drinking limits for healthy men younger than 65 are no more than five drinks at a single occasion or 14 drinks a week; and for women younger than 65, no more than four drinks at a single occasion or eight a week. The limit for those 65 and older is one drink a day, or no more than eight per week.

Screening

There are a variety of validated screening tools administered through direct questioning by a physician or other health professional. The CAGE questions are succinct and simple.

C: Have you ever felt you should cut down on your drinking?

A: Have people ever annoyed you by criticizing your drinking?

G: Have you ever felt guilty about your drinking?

E: Have you ever had a drink first thing in the morning (an eye-opener) to steady your nerves or to get rid of a hangover or residual drug effect?

Any positive answers deserve further evaluation. Two or more positive answers are likely to indicate a significant drinking problem.

In addition, consider the use of online screening. Visit, for example, AlcoholScreening.org, a project of the Boston University School of Public Health's Demand Treatment initiative for a self-administered questionnaire with immediate feedback (link).

Diagnosis

After an initial screening has yielded a positive result, you will need to examine the criteria for making a diagnosis of alcohol abuse or alcohol dependence.

Ask the following screening questions to aid in the diagnosis of alcohol abuse: In the past 12 months, have you experienced:

• Failure to fulfill major role obligations at work, school or home because of recurrent drinking?
• Recurrent drinking in hazardous situations?
• Recurrent legal problems related to alcohol?
• Continued use despite recurrent interpersonal or social problems?

One or more positive answers for any time in the previous 12 months suggests alcohol abuse.

Ask these screening questions for the diagnosis of alcohol dependence: In the past 12 months, have you experienced:

• Tolerance?
• Withdrawal syndrome or drinking to relieve withdrawal?
• Impaired control?
• Drinking more or longer than intended?
• Neglect of activities related to your drinking?
• Excessive time spent drinking or recovering from effects of drinking?
• Continued drinking despite recurrent psychological or physical problems?

Three or more positive answers for any time in the previous 12 months suggests alcohol dependence.

Act early to prevent addiction

Although much of the scientific literature focuses on prevention and treatment of addiction, the majority of health, family and social problems related to alcohol use occur in nondependent persons who are drinking in excess of recommended levels. As a result, experts are beginning to advocate for the public health benefits of intervening with problem users without waiting for addiction to develop.

Clinical experience with screening and brief intervention consistently shows that physicians can effectively change their patients' unhealthy behavior, including their harmful drinking. Because of the stigma that surrounds drinking problems, physicians may assume that the outcomes of addressing such problems are discouraging. Quite the contrary.

More than 20 studies have found positive behavior change in patients when physicians have performed screening and brief intervention. Physicians are already accustomed to modifying a range of patient behaviors and conditions, including poor dietary habits, smoking, elevated cholesterol or blood pressure levels, and noncompliance with taking medications. Unhealthy drinking should be added to the list.

Once the problem has been identified, the next step is a brief intervention, referral for follow-up treatment, or both. Brief interventions are time-limited, patient-centered counseling strategies. The physician should be nonconfrontational, and provide educational materials to the patient. Offer choices on how to make changes and emphasize the patient's responsibility for changing drinking behavior. Convey confidence in the patient's ability to change drinking behavior.

Research consistently supports the cost-effectiveness of brief interventions for problem drinkers in primary care and ED or trauma settings. Various studies have shown that emergency physicians' interventions decreased subsequent alcohol use and readmission for traumatic injuries and reduced the number of drinking and driving incidents, traffic violations and alcohol-related injuries, including motor vehicle crashes and alcohol-related problems among 18- and 19-year-olds.

In trauma centers, individuals who received a brief intervention had 48% fewer readmissions to the hospital and 28 fewer drinks per week than patients who did not receive attention to their drinking problems. Although the prevalence of alcohol problems is highest in trauma patients, incredibly, only 15.5% of the patients hospitalized for trauma had any indication in their medical records that alcohol use or intoxication had been identified. For every $1 spent on alcohol counseling for injured patients, hospitals can expect to save $3.81.

Screening: the standard of care

This commentary is hardly alone in promoting the need for screening as a standard of care. Many federal agencies and national medical organizations have developed initiatives to train physicians and other health care professionals more adequately.

Among federal agencies, key resources are the U.S. Preventive Services Task Force; Substance Abuse and Mental Health Services Administration, with its Center for Substance Abuse Treatment; and the Health Resources and Services Administration's Project Mainstream. The Veterans Health Administration and the Dept. of Defense released a clinical practice guideline for substance-use disorders.

Other national organizations working on screening are the American College of Surgeons' Committee on Trauma; the National Committee for Quality Assurance; and the American Medical Association, which has developed policies on alcohol and other drug screening and testing (link).

The saddest part of this story is that while we have not been identifying and treating alcohol problems, we have been treating the complications of drinking with great skill and diligence. Those are presenting, at an enormous cost to the patient and health care system, in the form of cardiac arrhythmias, hypertension, depression, anxiety, insomnia, liver disease and trauma.

We must start identifying and treating alcohol problems as early as possible. Furthermore, alcohol (and other drugs) can adversely affect prescribed and over-the-counter medications, and failure to screen for alcohol problems can also lead to misdiagnosis and potentially harmful treatment.

Our professional and ethical mandate should be that every patient be screened for unhealthy alcohol use as a standard of care and, when needed, receive appropriate follow-up care. Not to do so is a major opportunity lost for the practice of medicine and for hundreds of thousands of patients and their families as well.

David C. Lewis, MD, Donald G. Millar Distinguished Professor of Alcohol and Addiction Studies, Brown University, Providence, R.I.