Medscape recently interviewed Tom Frieden, MD, MPH, Director, US Centers for Disease Control and Prevention, about the need for alcohol screening and counseling and the best ways to make this a routine part of everyday clinical practice.
Tom Frieden, MD, MPH: At least 38 million adults in the United States drink too much alcohol, leading to a wide range of negative consequences, including heart disease, breast cancer, sexually transmitted diseases, fetal alcohol spectrum disorders, motor vehicle crashes, and violence. Drinking too much includes binge drinking or high per-occasion use (5 or more drinks on an occasion for men and 4 or more for women), high weekly use, and any alcohol use by pregnant women or those under age 21.
Drinking too much alcohol accounts for about 88,000 deaths in the United States each year and is the fourth leading preventable cause of death. In 2006, it cost the United States about $224 billion. And although this may be a surprise, most people who drink too much are not alcoholics.
Tom Frieden, MD, MPH, Director, US Centers for Disease Control and Prevention
More than 30 years of research has shown that alcohol screening and brief counseling is effective at reducing risky drinking. However, this month's Vital Signs reports that only 1 in 6 adults -- and only 1 in 4 binge drinkers -- say that a healthcare professional has ever talked about alcohol use with them. We need to work toward making alcohol screening and brief counseling routine.
Medscape: How many US adults drink too much?
Dr. Frieden: An estimated 30% of adults misuse alcohol, with most engaging in high daily, weekly, or per-occasion use which results in the increased risk for health consequences. However, only about 4% of the US population is alcohol dependent. Drinking too much is dangerous and is associated with many health and social problems, including heart disease, breast cancer, sexually transmitted diseases, unintended pregnancy, fetal alcohol spectrum disorders, sudden infant death syndrome, motor vehicle crashes, and violence.
Medscape: Is it realistic to expect health professionals to do anything about this problem?
Dr. Frieden: Absolutely. Health professionals are already asking screening questions on an array of risk factors and may even have information about alcohol use on patient history forms. It's simple to add alcohol screening questions to these forms. The counseling interventions are also brief (6-15 minutes), involve the patient's active participation, and do not have to be provided by a physician, but can be provided by other health professionals, including nurses, social workers, and psychologists.
Screening and counseling can also be provided electronically to save staff time.
There are many resources for clinicians and public health practitioners with tips on brief counseling with patients who are drinking too much. In addition, the Affordable Care Act requires new health insurance plans to cover alcohol screening and brief counseling without a copayment.
Medscape: Would you describe the latest guidelines on screening and counseling in healthcare settings? What is the evidence about how well they work?
Dr. Frieden: There are a number of validated screening tools to assess alcohol use, including the AUDIT, AUDIT-C, and a single-question screen for number of days in a year of binge-level alcohol use. Counseling or a brief conversation with those who drink too much can then inform the patient about health problems that could occur as a result of their drinking, and set goals and a plan for reducing drinking if the patient wants to do so. Patients who agree to reduce their drinking are then followed to assess their success.
Counseling interventions are brief (6-15 minutes) screening sessions that can help:
• Reduce average alcohol use by over 3 drinks per week;
• Reduce episodes of binge-level alcohol use by 12%; and
• Improve adherence to recommended drinking limits.
These effects can last for years and can also lead to reduced healthcare utilization, including fewer hospital days and lower costs. A very small percentage of those who are screened will have indications of alcoholism or a severe alcohol use disorder. These patients can be referred for specialized treatment.
Medscape: Would you describe an ideal screening and counseling intervention in, for example, a primary care outpatient setting, perhaps during an office visit?
Dr. Frieden: Alcohol screening can be done using a set of validated questions, such as the AUDIT, AUDIT-C, or even a single question about days of binge-level alcohol use in the past year. These questions can be worked into an existing patient questionnaire or asked of patients during other clinical activities. Scoring the screening questions typically takes no more than a few seconds. Only patients who screen positive will require counseling.
Alcohol screening and counseling is similar to smoking cessation interventions, with the use of motivational interviewing and the 5 A's of behavioral change intervention (ask, advise, assess, assist, and arrange). The clinician works with the patient to come up with a plan for reducing their drinking that takes into consideration their specific health issues as well as problems with functioning at home or work, and legal problems. Follow-up occurs in future visits to determine whether the patient's drinking and associated problems are improving.
Medscape: In what settings and in what age groups should health professionals consider screening? Which health professionals might carry out the screening and counseling most effectively -- physicians, NPs or PAs, RNs, or others?
Dr. Frieden: Alcohol screening and brief counseling can occur in primary care settings, trauma care settings, emergency departments, and many other health and social service settings. It can be delivered by social workers, nurses, psychologists, and others. Delivering alcohol screening and counseling by phone, computer, or mobile devices can also reduce the demand on staff time for delivering this service.
Medscape: Are there some successful or innovative programs that have used these guidelines in practice?
Dr. Frieden: One example of successful integration of alcohol screening and brief counseling into routine clinical care is Kaiser Permanente of Northern California. It has recently integrated this service into its primary care practices, covering 3.4 million members. During a 4-month period (July-November 2013) there were 230,000 brief interventions or referrals. Staff supported this implementation, in part because the screening process was built into their electronic health record (EHR) system.
Medscape: Tell us more about building screening into EHRs. What are the ways that alcohol screening and brief counseling can be integrated into EHRs?
Dr. Frieden: There are a variety of e-tools, including prompts and other reminder systems, that can be used to help clinicians integrate alcohol screening and brief counseling into their practices. The Community Preventive Services Task Force has also recommended the use of electronic methods (eg, use of computers, telephones, or mobile devices) to deliver components of alcohol screening and brief intervention. In addition, alcohol screening and brief counseling are being considered for inclusion as a meaningful use measure in EHRs, which could also help support the use of this service in clinical settings.
Medscape: In closing, what should clinicians do differently tomorrow to start to improve this situation?
Dr. Frieden: Doctors, nurses, and other health professionals can take 3 key actions:
• Counsel those who drink too much to drink less, using specific techniques such as motivational interviewing to establish a plan, and then reassess their success in future visits; and
• Advise pregnant women and underage youth not to drink at all.
They can also train staff to support the routine delivery of this intervention and make changes in the healthcare delivery system to ensure the success of alcohol screening and counseling activities.