New Guidelines for Alcohol Misuse in Adults Released

Deborah Brauser

May 15, 2013

Primary care physicians should ask all adults older than 18 years about their drinking habits, according to the final recommendation statement on alcohol misuse released this week by the US Preventive Services Task Force (USPSTF).

Based on recent studies, the new recommendations also state that brief behavioral counseling is effective and should be offered to any adult who screens positive for risky or hazardous drinking.

"If you look at behavioral risk factors, such as hazardous use of alcohol or tobacco or sedentary behavior, those are some of the root causes of a lot of preventable disease," Task Force member Sue Curry, PhD, dean of the College of Public Health at the University of Iowa in Iowa City, told Medscape Medical News.

"So having these risk factors addressed in the course of good preventive primary care makes perfect sense. At the end of the day, it leads to less illness, less family disruption, and less premature death," said Dr. Curry.

However, the Task Force notes that not enough evidence exists on how to identify and effectively treat adolescents who engage in these harmful behaviors. Therefore, they cannot recommend screening or interventions for this patient population at this time.

The new guidelines were published online May 14 in the Annals of Internal Medicine.

Risky Behaviors

According to the Task Force, approximately 30% of the US population engages in risky drinking behaviors.

Dr. Sue Curry

In addition, "alcohol misuse is the cause of tens of thousands of deaths per year in the United States — deaths that could have been prevented," said Dr. Curry in a release.

The Task Force's use of the term "alcohol misuse" applies to several behaviors, including risky or hazardous alcohol consumption. It also means drinking more than the amounts recommended by organizations such as the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

The last USPSTF statement on alcohol misuse was released in 2004.

The updated recommendations, which are based on a review of studies published between 1985 and 2011, state that "numerous instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity." Therefore, all adults older than 18 years, including pregnant women, should be screened.

The 3 recommended tools include the 10-question Alcohol Use Disorders Identification Test (AUDIT), the abbreviated 3-question Audit-Consumption (Audit-C), and single-question screening, such as asking how many times in the past year a patient had consumed more than the daily recommended drinking limits.

"Of available screening tools, AUDIT is the most widely studied for detecting alcohol misuse in primary care settings," write the Task Force. None of the 3 tools mentioned require more than 5 minutes to administer.

Behavioral Counseling

In addition, the Task Force found "adequate evidence" from past research that behavioral counseling interventions can lower the weekly consumption of alcohol, promote long-term compliance with recommended limits, and reduce binge drinking.

Although evidence of effectiveness for this type of intervention in pregnant women is limited, it was found to be effective among all women of childbearing age.

The most effective counseling interventions were found to be multicontact interventions lasting between 10 and 15 minutes each.

The Task Force did not assess pharmacotherapy or specific outpatient treatment program interventions, "but the benefits of specialty treatment are well-established and recommended for persons meeting the diagnostic criteria for alcohol dependence."

"The good news is that primary care professionals can really affect their patients' lives for the better by just asking a few simple questions — and then making sure everyone who is engaged in risky drinking gets counseling to get their drinking under control," said Dr. Curry.

The Task Force classified this as a grade B recommendation, which means a high certainty of a moderate benefit or a moderate certainty of a moderate to substantial benefit.

"This is based on the magnitude of the net benefit in consideration of any potential harms, as well as the certainty of that net benefit," explained Dr. Curry.

"In essence, an A recommendation is one in which there is very little doubt that there could ever be more science that would change the recommendation. A B recommendation says that there is adequate evidence of at least a moderate benefit. The B is still a robust recommendation," she said.

More Research in Teens Needed

The evidence of effectiveness for screenings or brief behavioral counseling in adolescents between the ages of 12 and 17 years was deemed "insufficient" and was classified as an "I statement," which means that the balance of benefits and harms of the intervention could not be determined.

"This doesn't mean there's bad science; it just means there isn't enough of it at this time," said Dr. Curry. "We recognize the critical need for more research on what primary care teams can do to help keep teens safe and sober."

"Although there is adequate evidence that brief behavioral counseling interventions improve several intermediate outcomes [in this age group], there is little direct evidence describing the ultimate effect of these interventions on longer-term morbidity, mortality, or quality of life," added the Task Force.

They note that, overall, they recognize that healthcare professionals base their decisions on more than evidence alone.

"Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms," they write.

NIAAA Agrees

"We applaud the efforts of the US Preventive Services Task Force. They've done a great job, and it's a very rigorous review of the literature," Robert Huebner, PhD, acting director of the Division of Treatment and Recovery Research at the NIAAA, told Medscape Medical News.

Dr. Robert Huebner

Dr. Huebner, who was not involved with this review, added that his organization concurs with the Task Force's recommendations on screening all adults and providing interventions if needed.

"The NIAAA has been supporting research in the primary care setting on screening and brief interventions for alcohol problems for well over 2 decades," he said.

He also applauds the field for having created "very brief but still rigorous" screening tools, as well as interventions that do not take up much time.

"It's just amazing that a relatively small dose of an intervention delivered at the right time and in the context of one's primary care office can have a huge impact. And there's training available. Primary care docs out there really have the potential to improve the public health," said Dr. Huebner.

"It's important to note that we're talking about people who are nondependent drinkers," he added. "As the report states, the evidence base for the effectiveness of these brief interventions has not been shown for people with serious forms of the disorder. But for most folks who come into the primary care office, this is a pretty straightforward, simple thing to do."

The 2 organizations differ a bit, however, when it comes to recommendations for treating adolescents. As shown on their Web site, the NIAAA has created a practitioner's guide to screening for alcohol and to providing brief interventions in youth between the ages of 9 and 18 years.

"The [USPSTF's] I statement isn't a recommendation against doing screening and brief interventions. It's just saying there's not enough evidence to say that the benefits outweigh the potential harms. And they're right!" said Dr. Huebner.

"The foundation for research findings for this is a work in progress. It's important to recognize that components of our practitioner's guide are evidence based, including the screening instruments and the counseling aspect. Individual elements of the guide are based on research and expert opinion," he explained.

He reported that to further build up this work in progress, the NIAAA has recently funded 6 studies that will use their guide in a variety of real-world settings "to see if providing these screenings and interventions really make a difference."

"Hopefully, in about 3 years or so, we should have much more in the way of evidence in answering these questions."

For now, Dr. Huebner recommends that clinicians rely not only on scientific evidence but should also use their own expert judgement. And if they decide to do screening and interventions for alcohol, healthcare professionals should use tools such as those recommended by the NIAAA.

"It's a bit of a judgement call on their part. But since the problem of harmful or hazardous drinking among youth is such a big deal, we think clinicians should utilize these tools."

The final USPSTF recommendation statement can be found on their Web site.

Ann Intern Med. Published online May 14, 2013. Abstract

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