MDs Fail to Screen for Excessive Alcohol Use in Young Adults

Deborah Brauser

October 27, 2011

October 27, 2011 — Clinicians often fail to ask young adults about excessive alcohol consumption, even though practice guidelines recommend universal screening, according to new research.

A survey of 4012 young adults found that only 14% of all participants who regularly exceed drinking limits were asked and advised about their alcohol patterns while visiting their physicians in the previous year.

Although the participants between the ages of 18 and 25 years were found to be the most likely to exceed the limits, they were also the least likely to be asked about it.

"Alcohol misuse, binge drinking, is the leading contributor to the leading cause of death among young people in the United States. And yet they're just not being questioned about their behaviors," lead investigator Ralph W. Hingson, ScD, MPH, director of the Division of Epidemiology and Prevention Research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Bethesda, Maryland, told Medscape Medical News.

Dr. Ralph W. Hingson

"We think physicians should be routinely asking all adults about their drinking and offering advice about the levels that pose the highest health risk. And this is particularly important for young adults," said Dr. Hingson.

The study was published online September 21 in the Journal of General Internal Medicine.

Screening Effective (When Used)

According to the researchers, there is strong evidence to support the effectiveness of screenings for unhealthy alcohol use among adults.

"Proactive guidelines recommend screening and physician advice, which could help address this common cause of injury and premature death," they write.

A release put out by the NIAAA reports that the American Medical Association, the American Society of Addiction, and the US Preventive Services Task force also all recommend routine screenings in primary care.

Dr. Hingson said that excessive alcohol consumption includes more than 4 drinks per day and more than 14 drinks per week for men, and more than 3 per day and more than 7 per week for women. He added that people who commonly exceed these levels are at "a sharp increase" for risk of illness or accident.

"Alcohol misuse in the United States is the third leading cause of death, accounting for 79,000 deaths every year," reported Dr. Hingson.

The investigators enrolled 3409 adult current or former drinkers between the ages of 18 and 39 years (51.3% men; 66.4% white, 16.2% Hispanic, 10.6% black) into this study. All patients participated in a national survey conducted in 2006.

The survey asked about demographic information, past physician visits, and drinking patterns.

Not Enough Training, Time?

Results showed that 47% of all participants exceeded either the daily or weekly drinking limits, and 13% exceeded both.

Those between the ages of 18 and 25 years were significantly more likely to exceed weekly and/or daily drinking limits than those aged 26 years or older (68% vs 56%; P < .001).

Of all participants, 66.8% made physician visits in the past year. Of these, the individuals aged between 18 and 25 years were asked significantly less often about their drinking than those who were older (34% vs 54%; P < .001).

The percentage dropped even lower for the youngest participants, as only 26% of those between the ages of 18 and 20 years were asked about their drinking patterns.

The investigators note that there are several potential barriers to routine alcohol screenings, including the belief by clinicians that they take considerable time to perform, require specialized training, and are often not reimbursed.

However, brief screening tools are now available, including one recently reported on by Medscape Medical News; easy-to-use training resources are also easy to find; and new billing codes have recently been established, write the investigators.

In addition, Medicare recently announced that it will now cover annual alcohol screening.

"The findings reported by Dr. Hingson and his colleagues indicate that we must redouble our efforts to help clinicians make alcohol screening and brief intervention a routine part of patient care in the United States," said Kenneth Warren, MD, acting director of the NIAAA, in a release.

He adds that a guide providing "a research-based, simplified approach" to screening is now available on the NIAAA's Web site for both primary care and mental health clinicians. The site also provides downloadable forms and information on other screening resources.

Reluctance to Deal with the "Unknown"

Michael F. Fleming, MD, MPH, professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine in Chicago, Illinois, recently organized a conference at Northwestern that brought together national experts to discuss ways to reduce drinking by college students.

At the conference, he led a presentation on why physicians do not screen for alcohol misuse more often.

"I think some physicians feel they don't get enough training in how to do interventions. Others feel that it takes too much time and distracts them from other things they should normally be doing," Dr. Fleming told Medscape Medical News.

"But other issues, such as reimbursement, have gone away. The evidence is pretty strong now in terms of how well screenings and interventions work. So it's really about not wanting to deal with the unknown."

He noted that clinicians should look to the current screening model for smoking.

"For many years, doctors never asked about smoking, but now it's pretty routine. Once they were told they had to do it and they were reimbursed for it, they started doing it. It's just getting a new mindset," said Dr. Fleming.

"Also, educating physicians and training them in these skills is important, but it's also a systems issue. Doctors follow what is standard of care in their practice. So if their practice, group practice, [health maintenance organization], or whatever system they're in makes this as part of standard of care and establishes what 'normal' is, then that can change things."

He also said it is important for clinicians to realize that alcoholics and high-risk drinkers are 2 separate groups.

"It's pretty easy to identify the alcoholic. But it's the high-risk drinkers that get into the most trouble and tend to be the ones who are hurting people out on the highways."

The study was supported in part by a grant from the NIAAA. Dr. Fleming and all but 1 of the study authors, including Dr. Hingson, have disclosed no relevant financial relationships. The other study author reports several potential conflicts of interest, which are listed in the original article.

J Gen Intern Med. Published online September 21, 2011. Abstract

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