Monday, July 1, 2019

Helping our patients reduce unhealthy alcohol use

- Jennifer Middleton, MD, MPH

The June 15 issue of AFP includes several excellent resources to aid family physicians in efficiently and effectively responding to unhealthy alcohol use. With an estimated 88,000 deaths every year in the United States related to alcohol, screening and intervening can be lifesaving and are recommended by the United States Preventive Services Task Force (USPSTF) (B recommendation).

This AFP USPSTF update article reviews the definition of unhealthy alcohol use:

The USPSTF uses the term unhealthy alcohol use to define a spectrum of behaviors, from risky drinking to alcohol use disorder (e.g., harmful alcohol use, abuse, dependence). Risky or hazardous alcohol use means drinking more than the recommended daily, weekly, or per-occasion amounts, resulting in increased risk for health consequences but not meeting criteria for alcohol use disorder.

The article discusses optimal screening instruments, all of which are very brief, such as the AUDIT-C and the SASQ. The perhaps better known CAGE is less useful because it can miss risky alcohol use that doesn't meet criteria for alcohol dependence disorder. A positive screen should prompt follow-up with a more in-depth instrument such as AUDIT. The meta-analysis that informed the USPSTF recommendation statement, however, noted that in "population groups with lower prevalence of unhealthy alcohol use—older adults, pregnant women, and adolescents—the estimated positive predictive value [of AUDIT] was much lower." For older adults, consider using CARET, and, for pregnant women, consider using TWEAK or T-ACE. Although the USPSTF deemed the evidence insufficient for making a recommendation regarding screening adolescents (I recommendation), CRAFFT is one tool available for family physicians wishing to screen this group.

The USPSTF found that a median of 30 minutes of brief intervention was effective in reducing unhealthy alcohol use. Screening, Brief Intervention, and Referral to Treatment [SBIRT] was commonly employed in these studies as was motivational interviewing, simple education regarding alcohol consumption recommendations, and several cognitive behavioral strategies. 6-12 months following these interventions, the previously mentioned meta-analysis found a mean decrease of 1.6 drinks per week; in binge drinkers (heavy episodic use), total drinks per week decreased from a mean of 26.0 to a mean of 19.1. Trials in pregnant women, which tended to use abstinence as an outcome, found pooled odds ratio [OR] for abstinence after intervention, compared to no intervention, of 2.26 (95% CI, 1.43 to 3.56)

After reading the AFP USPSTF update article, you can test your knowledge by reviewing these case studies and accompanying answers. The Substance Abuse and Mental Health Services Administration's (SAMHSA) SBIRT website includes a lengthy list of online resources covering different patient care settings with a variety of methods (articles, videos, patient education, and even a free online training course). The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has both in-depth and pocket guides titled "Helping Patients Who Drink Too Much" available online. This FPM article, referenced in an accompanying AFP editorial, reviews alcohol screening and brief intervention strategies, includes an excellent 4-minute video example of a brief intervention, and also reviews billing and coding for these services.