New Guidance on Screening, Intervention for Alcohol Misuse

Laurie Barclay, MD

March 02, 2015

New guidance for physicians and policy-makers describes screening and intervention for high-risk alcohol drinking, based on a review published online March 2 in the Canadian Medical Association Journal. The evidence-based review targets healthcare providers and policy-makers who are not specialists in substance abuse or addiction. An accompanying commentary recommends policy changes and use of validated screening tools.

"Canadian guidelines on low-risk drinking, published in 2011, highlight the national importance of tackling risky alcohol use," write Anne Moyer, PhD, from Stony Brook University in New York, and John W. Finney, PhD, from the VA Palo Alto Health Care System in Menlo Park, California.

"Health care providers who are not addiction specialists are well positioned to identify individuals who drink and can play an important role in lowering risky alcohol use," they continue.

"Screening and brief interventions may reduce the toll of risky or harmful drinking."

According to current Canadian guidelines, low-risk drinking constitutes not more than 10 drinks per week and not more than two drinks per day on most days for women. For men, low-risk drinking does not exceed 15 drinks per week or three drinks per day on most days. Pregnant women should not drink any alcohol.

However, about 15% to 20% of Canadians exceed these limits, resulting in significant disability and 7.1% of mortality in Canada, according to the accompanying commentary, by Sheryl Spithoff, MD, from Women's College Hospital, and Suzanne Turner, MD, from St. Michael's Hospital, both in Toronto, Ontario, Canada. The review authors therefore recommend population interventions, including alcohol regulation and pricing, and individual strategies, including education, screening, and intervention.

Despite the reluctance of some clinicians to inquire about excessive drinking, patients may prefer to be screened and treated in a primary care or hospital setting. Interventions in these settings may be less embarrassing, stigmatizing, or inconvenient than treatment in the office of an addiction specialist or formal alcohol treatment program.

Specific Clinical Recommendations

  • Clinicians should ask patients whether they drink alcohol, and in what quantity (how many days per week; how many drinks per day).

  • Clinicians should counsel patients with risky drinking and provide feedback with the FRAMES approach (feedback of risk, responsibility for change, advice, menu of options, empathy, and self-efficacy), taking about 5 to 15 minutes.

  • Clinicians should follow-up patients over the course of several weeks or months.

  • Clinicians should give patients educational materials geared at behavioral strategies to reduce drinking.

  • Clinicians should refer patients who continue or increase at-risk drinking for specialty treatment.

Policy Changes, Validated Screening Needed

"[P]atients with at­risk drinking and alcohol use disorders can be easily identified with validated screening procedures," write the commentators. "Conversely, when physicians rely on case identification alone, patients with at­risk drinking and milder alcohol use disorders (who typically have stable lives and few consequences from drinking) are often missed. These patients, however, are at high risk of harm and of progression to more severe disease, so effective interventions are important."

To improve alcohol screening and interventions, the editorialists recommend the following policy changes:

  • Improve physician education on alcohol misuse and strategies to ensure better access to appropriate treatment, which should improve health outcomes and reduce healthcare costs.

  • Provide mandatory training in screening and managing at-risk drinking for graduates in the fields of primary care and emergency care.

  • Implement systematic screening and brief intervention programs at primary care clinics and hospitals.

  • Improve access to ongoing addiction treatment for patients with more severe alcohol use disorders.

  • Include first-line medications for alcohol use disorders on the general public formularies of provinces and territories.

  • Use billing codes reflecting the complexity of alcohol misuse interventions, so that provinces and territories can appropriately compensate clinicians.

"Although screening and brief interventions for risky or harmful drinking have considerable empiric support, their effectiveness and cost-effectiveness for misuse of other drugs remains to be determined," the authors conclude. "Hampering such efforts is the lack of a practical, brief screening instrument for identifying problematic drug use. Determining the types of clients for whom various intensities and numbers of sessions of brief interventions are appropriate is another question needing more empiric evidence."

The review authors and commentators have disclosed no relevant financial relationships.

CMAJ. Published online March 2, 2015.


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