Alicia Ault

March 29, 2016

WASHINGTON ― Despite the fact that a growing number of older Americans have problems involving the use of alcohol, physicians still do not routinely offer universal screening, brief intervention, and referral to treatment (SBIRT) for drinking, despite established efficacy, new research shows.

Data presented here at the American Association of Geriatric Psychiatry (AAGP) 2016 Annual Meeting revealed that by 2020, 4.4 million adults will need treatment for alcohol use disorder, a 60% increase from 2000.

Study investigator Rushiraj Laiwala, MD, said that in contrast to the past, when individuals tended to drink less as they got older, today the reverse is true.

The total percentage of those aged 65 years and older who drink and who engage in heavy and binge drinking is on the rise, said Dr Laiwala, a geriatric psychiatry fellow at the University of South Carolina School of Medicine, in Columbia.

Because of the growing population of older Americans, the number of heavy drinkers will increase from 1 million currently to 2 million by 2060. The number of binge drinkers will increase from 4 million to 9 million by 2060, said Dr Laiwala.

And yet, he said, "we know that older drinkers are less likely to be identified compared to their younger counterparts."

Rebecca Payne, MD, assistant professor of psychiatry at the University of South Carolina School of Medicine, who presented an overview of SBIRT, said that alcohol use is frequently missed in patients of all ages.

"We do know that physicians in general are less likely to ask their older patients about drinking specifically compared to younger patients," Dr Payne told Medscape Medical News.

"It's been proven that we can cut down on hazardous drinking by physician's advice, but we still aren't doing it," Lawrence Schonfeld, MD, professor emeritus of mental health law and policy at the Louis de la Parte Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida, in Tampa, told Medscape Medical News.

Simple, Reimbursable

Dr Schonfeld, who was not involved in the AAGP presentation, developed the Florida BRief Intervention and Treatment of Elders (BRITE) project. The study was funded initially by the state and then through a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA).

The study included SBIRT data on some 85,000 individuals aged 55 years or older at primary and geriatric practices, aging and mental health services centers, and urgent care clinics, among other sites. BRITE ran from 2006 to 2011.

Time is the major reason physicians are reluctant to screen or offer interventions, said Dr Payne. Clinicians may also feel that they have a knowledge or training deficit ― for example, they may feel unsure about sending patients for treatment. Personal and family history of alcohol use may also contribute to a hesitancy to screen.

Patients, on the other hand, seem to be willing to be screened, said Dr Payne. In a 2006 survey, 92% said they would give an honest answer if asked about their drinking, and 93% said they thought their physician should ask how much they drink, she said.

If physicians are not doing the most basic screening, "they're not going to be asking critical questions, like, How much are you drinking?" said Dr Schonfeld. The BRITE project found that aging services sites did a better job than physicians at both screening patients and offering follow-up treatment and referrals (Am J Public Health. 2015;105: 205–211).

Both Dr Schonfeld and Dr Payne noted that physicians may also be reluctant to use SBIRT because they think they are not going to be paid for their time.

Medicare, private insurers, and some Medicaid programs pay for SBIRT, with pay differing by whether it is a 15-minute or 30-minute screening and intervention service. The primary codes for commercial insurance are 99408 and 99409, and Medicare has several G codes that apply, including 396, 397, 442, and 443.

New View of Drinking

The National Institute on Alcohol Abuse and Alcoholism recommends that people older than 65 years should have no more than seven drinks a week and no more than three drinks on any one day.

But the agency has also proposed a new way of looking at drinking, with new terms ― low-risk and at-risk or heavy drinking.

Dr Payne advocates universal screening for all patients and that it become incorporated into practice. First, patients should be asked a prescreening question, which could be, "Do you sometimes drink beer, wine, or other alcoholic beverages?" She encourages use of such language because some people may not consider beer or wine to be alcohol. A negative answer requires no further screening.

With a positive response, patients can be prodded to the next level, which may incorporate the Short Michigan Alcohol Screening Test–Geriatric Version, the Michigan Alcoholism Screening Test– Geriatric Version, the CAGE Questionnaire, or the Alcohol Use Disorders Identification Test.

Those "can be delivered by you or anyone in your office," said Dr Payne. "Whatever makes the most sense to you and applies the best to your clinical practice, use it," she said.

Physicians should review the patient's responses with them. "It sends the message that you actually looked at it, and you can clarify any questions they might have about it."

The brief intervention is a discussion focused on raising awareness of use; it motivates the individual toward change. It can consist of one to five sessions, she said.

Physicians can give the patient information on how their drinking compares with recommendations of the NIAAA and what impact alcohol might have on medications or sleep patterns, for instance. Dr Payne said she asks patients to come up with a change plan. The plan is discussed with the patient and is revisited within an agreed-upon period.

Only about 5% of patients need referral to treatment, said Dr Payne.

Dr Srinivasan is the principal investigator on a SAMHSA SBIRT training grant. Dr Laiwala, Dr Payne, and Dr Schonfeld have disclosed no relevant financial relationships.

American Association for Geriatric Psychiatry (AAGP) 2016 Annual Meeting: Session 104, presented March 17, 2016.

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