CDC Urges Physicians to Ask About Alcohol

Deborah Brauser

January 07, 2014

REVISED 1/8/14 with added comments: Despite the fact that more than 38 million adults drink too much and that excessive alcohol use accounts for 88,000 deaths in the United States each year, healthcare providers do not ask patients about how much they drink, a new report from the Centers for Disease Control and Prevention (CDC) concludes.

Released today, the Vital Signs report shows that only 1 in 6 of all participants and 1 in 4 of binge drinkers who were evaluated reported that a clinician had discussed alcohol use with them. And only 1 in 3 of those who reported binge drinking more than 9 times a month had ever had a healthcare professional even broach the subject.

"Alcohol screening and brief interventions, which include brief counseling, can substantially reduce the amount of alcohol consumed. But unfortunately, it's not happening often enough," said CDC director Thomas Frieden, MD, MPH, during a press conference.

Dr. Frieden added that all healthcare professionals should screen all adult patients as part of normal clinical care.

"We really do want this to be routine. We know that if doctors try to use their preconceived notions of who may be at risk, they get it wrong. So if you don't ask, you don't get the answer," he told Medscape Medical News.

"The bottom line is: drinking too much is a big problem among US adults and shouldn't get a free pass when it comes to screenings."

Dr. Frieden speaks at length with Medscape Medical News in a featured commentary.

High Cost of Alcohol Abuse

CDC investigators evaluated data for 166,753 adults aged 18 years and older from 44 states and the District of Columbia (DC) who participated in the annual Behavioral Risk Factor Surveillance System telephone survey. All were asked between August and December 2011 about alcohol use and possible discussions with healthcare providers.

Dr. Thomas Frieden

"For every 1 person who is an alcoholic, there are about 6 who are problem drinkers, drinking enough to adversely affect their lives, their health, their work situation, or their family situation, but who are not alcoholic," said Dr. Frieden.

The CDC defines "drinking too much" as high average weekly use and/or any binge drinking, as well as any use of alcohol by those younger than 21 years or by those who are pregnant.

"Drinking too much…was responsible for about $224 billion in economic costs in 2006," the organization reported in a release.

However, they noted that alcohol screening and brief intervention (ASBI) "can reduce the amount of alcohol consumed on an occasion by 25% among those who drink too much. It is recommended for all adults, including pregnant women."

Unfortunately, only 17.3% of the pregnant women who participated in the current survey reported that a health professional ever talked with them about their drinking.

And only 1 in 6 of all participants reported talking with any healthcare professional about alcohol use. Those between the ages of 18 and 24 years had the highest prevalence of patient-reported communication, at 27.9%, whereas only 9.3% of those 65 or older reported having these discussions.

Screening Is Simple, Effective

The state with the lowest prevalence of alcohol communication was Kansas (8.7%); the highest prevalence was found in DC (25.5%). Ever discussing alcohol use was also significantly higher for men than for women (19% vs 12.5%, respectively) and higher for Hispanics and blacks (22.5% and 19.4%, respectively) than for whites (13.7%).

"Excess drinking is a serious problem in our society. We have a tool, a technique that works really well, but it's not being applied," said Dr. Frieden, when asked about ASBI.

He explained that alcohol screening can be done simply by using a form or even just asking a couple of questions. Brief counseling "is a conversation with a health worker, whether that's a doctor or nurse or a variety of other people in the healthcare system, that focuses on what the patient is doing and wants to be doing and a plan for what the patient will do in the future."

"It sounds so simple, but this is very effective for many patients. It can help people set realistic goals and help them achieve those goals," he said. "And it takes only a few minutes to deliver."

Because the US Preventive Services Task Force (USPSTF) currently recommends the use of ASBIs in clinical practice, these services will be covered by most health insurance plans without copays through the Affordable Care Act.

Health professionals can implement ASBI "by developing support in medical practice using current guidelines, developing a plan and making it standard practice, training staff on how to deliver the service, and then testing and refining it," said Dr. Frieden.

Alcohol Addiction Under-recognized

The CDC reports that the federal government is currently working to increase screening and counseling for alcohol use at federally qualified health centers and now requires states to expand Medicaid to cover preventive services.

However, they note that despite public health efforts to increase ASBI, the finding that only 1 in 6 of the survey's participants had a health professional ever discuss alcohol behaviors with them "has changed very little in the past 15 years."

Dr. Frieden noted that issues of alcohol use and addiction have traditionally been under-recognized in the healthcare system. Reasons could include that clinicians are afraid they will not have time to deal with a positive answer, that they may be afraid of stigma, or that "they may think incorrectly that a patient is not willing to enter into a discussion of the issues."

"Doctors are busy and have lots of things to do. But we can build in screenings into routine registration and general background questions. It's quite important," he told Medscape Medical News.

"We're not saying that no one should drink. But new data we're releasing today show that the health system is not doing an effective job of finding out about problems," said Dr. Frieden. "So have a conversation with patients about their drinking patterns and ways to not cause any harm."

Major Health Problem

"I agree that this is a major public health problem ― and has been for a long time," John A. Renner, MD, member of the American Psychiatric Association's Council on Addiction Psychiatry, told Medscape Medical News when asked for comment.

Dr. John Renner

Dr. Renner, who is also a professor of psychiatry at Boston University School of Medicine in Massachusetts and director of the Addiction Psychiatry Fellowship at Boston University and at the VA Boston Health Care System, noted that healthcare has not traditionally done a very good job in either identifying these types of problems or intervening when needed.

"From my perspective, I would suspect that physicians every day see 2 or 3 or more people with an alcohol problem. The research suggests that most of the time it's missed. And even when it's fairly obvious, most physicians don't feel comfortable with how they should handle it. So they sometimes ignore it or don't handle it as effectively as they'd like."

He suggested that reasons for this include that "historically, this is not something that has been very well taught in medical schools" or in most residencies and that many clinicians have been concerned about coverage.

However, with the Affordable Care Act, "we'll finally have a situation where insurance will be required to cover these services and physicians can be reimbursed. But this has been a long time coming," said Dr. Renner.

As for getting the additional training needed to make ASBIs part of routine practice, he suggested that getting reimbursement for these services will give added incentive to reluctant clinicians.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has issued evidence-based clinician guidelines and training materials regarding ASBIs, which are available on their Web site. In addition, the CDC recommends the online Guide to Community Preventive Services (Community Guide), which lists several recommended policies and interventions to prevent the practice of drinking too much.

"Nobody's talking about prohibition. But they are saying that there are risky, unhealthy ways to drink, and people need to be educated that that can be dangerous," said Dr. Renner.

"For clinicians, everyone is feeling overburdened, and there are far too many requirements and demands than people actually have the time for. But this is a major health problem in the United States. The costs to the system and to individuals are tremendous, but the long-term payoff, if we can be effective, is great."

The full report is available online on the CDC's Web site.

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