USPSTF: Screen Adults, Pregnant Women for Unhealthy Alcohol Use

Diana Phillips

November 13, 2018

Primary care clinicians should screen all adults, including pregnant women, for unhealthy alcohol use and provide brief behavioral counseling interventions for those who screen positive, according to the US Preventive Services Task Force (USPSTF).

However, the final 2018 recommendation statement cites insufficient evidence for screening and counseling for alcohol use in adolescents — a conclusion that has raised concerns among multiple experts and appears to be inconsistent with recommendations from various medical groups, including the American Academy of Pediatrics.

The 2018 final recommendation statement was published online November 13 in the Journal of the American Medical Association.

To update its earlier recommendation, the USPSTF commissioned a systematic evidence review to examine the effectiveness of alcohol use screening in reducing unhealthy drinking and to prevent associated morbidity, mortality, and risky behaviors. The authors of the evidence review also evaluated various screening approaches, the effectiveness of counseling interventions, and the harms of screening and behavioral interventions.

Unhealthy alcohol use (referred to in the 2013 guidelines as "alcohol misuse") spans a spectrum of behaviors, from "risky" drinking to alcohol use disorder (AUD), according to the USPSTF. Risky or hazardous drinking refers to alcohol intake that exceeds limits established by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) of no more than four drinks per day or 14 drinks per week for men and no more than three drinks per day or seven drinks per week for women. Alcohol use disorder refers to harmful alcohol use, abuse, or dependence.

With respect to screening, the USPSTF determined that there is adequate evidence that the use of brief screening instruments in primary care settings can detect unhealthy alcohol use with "acceptable sensitivity and specificity" among adults older than 18 years and pregnant women.

For screening, one- to three-item instruments such as the abbreviated Alcohol Use Disorders Identification Test–Consumption and the NIAAA-recommended Single Alcohol Screen Question (SASQ) provide the most accurate assessments, according to the statement. In contrast, the Cut down, Annoyed, Guilty, Eye-opener (CAGE) instrument is not an accurate screening tool for the purposes of this recommendation because it is designed to detect alcohol dependence only, rather than the "full spectrum of unhealthy alcohol use," the authors write.

The task force also indicated that there is adequate evidence to show that brief behavioral counseling for adults who screen positive can reduce unhealthy alcohol use. The interventions included in the assessment varied in their design, duration, and number of interactions. Most of the interventions — 30% of which were Internet-based — consisted of four or fewer sessions with 2 hours of contact time or less (median, 30 minutes).

The interventions that targeted adults, including pregnant and postpartum women, typically took place in primary care settings and often used the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach. "Most interventions involved giving general feedback to participants (eg, how their drinking fits with recommended limits, or how to reduce alcohol use)," the authors explain. "The most commonly reported intervention component was use of personalized normative feedback sessions, in which participants were shown how their alcohol use compares with that of others," they write. They note that this technique was often combined with motivational interviewing or more extensive cognitive-behavioral counseling.

Although the task force was not able to identify specific intervention characteristics that were clearly associated with improved outcomes, they issued a B recommendation, which indicates "a high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial."

For example, for adults who screen positive for unhealthy alcohol use, behavioral interventions are associated with reductions in both the odds of exceeding recommended drinking limits and heavy use episodes at 6- to 12-month follow-up. Similarly, for pregnant women, brief counseling interventions increased the likelihood of abstinence from alcohol during pregnancy.

The evidence supporting primary care–based screening and brief counseling in the adolescent population (aged 12-17 years) was deemed insufficient to balance the benefits and harms, leading to the task force's I recommendation for these interventions.

Despite the task force's determination that there was insufficient evidence to support screening in adolescents, both the NIAAA and American Academy of Pediatrics recommend the Car, Relax, Alone, Forget, Family, Friends, Trouble (CRAFFT) screening instrument for identifying risky substance use in adolescents. The NIAAA also recommends asking patients about their own alcohol use as well as about their friends' alcohol use, the USPSTF writes.

In an assessment of current practice, "[r]esearch suggests that although a majority of pediatricians and family practice clinicians report providing some alcohol prevention services to adolescent patients, they do not consistently screen and counsel for alcohol misuse," the USPSTF writes. Also, the quality of screening practices, the tools used, and the interventions provided vary widely. Reported barriers include lack of time, lack of knowledge about best practices, and lack of services for adolescents who screen positive.

"A Call to Action"

The USPSTF's I statement regarding the screening and counseling of adolescents, which is unchanged from 2013, should be considered a call to action, Carolyn A. McCarty, PhD, of the Department of Pediatrics, University of Washington, Seattle, and colleagues write in an accompanying editorial. They note that it runs counter to recommendations from not only the American Academy of Pediatrics and the NIAAA but also the American Society of Addiction Medicine and the US surgeon general.

"We need to set a research agenda that will give us the information needed to definitively guide us toward what seems to be an emerging consensus: substance use disorders should be identified and addressed in primary care," they state.

In a separate editorial, Angela Bazzi, PhD, and Richard Saitz, MD, of Boston University School of Public Health, echo the importance of a more robust research agenda around primary care–based screening and interventions for unhealthy alcohol use by adolescents.

"It is particularly important to reduce drinking among youth because risk taking is common, alcohol-related injury is a leading cause of death among adolescents and young adults, and age of first drink is strongly associated with development of [alcohol use disorder]," they write. "Further, it is likely that screening and brief counseling for adolescents could be as efficacious — if not more — than among adults, because drinking patterns among adolescents have yet to be established and the potential to prevent a lifetime of risky exposures and consequences is significant."

Bazzi and Saitz also call for further studies to understand how to improve implementation of screening and counseling interventions across age groups. Despite the USPSTF's long-standing recommendations, implementation "still remains quite low, despite the high prevalence of unhealthy alcohol use, its association with death and disability, evidence for screening and brief intervention efficacy, substantial government funding, practice guidelines, and quality measures and incentives," they write. "Even when screening is performed, validated questionnaires are infrequently used. Reasons for low uptake may include challenges related to implementation, perceptions of alcohol use, and clinicians' perceptions of their roles."

In particular, specialized training and resources for physicians are needed, they continue. "The opioid epidemic and establishment of addiction medicine as a medical specialty will likely help improve physician training, but more will be needed to implement universal screening." Other efforts include providing ongoing support to facilitate screening and counseling via skills training, interdisciplinary association, and electronic record and decision support tools. In addition, physicians should be offered the necessary resources to care for AUD patients in general health settings.

Finally, they editorialists call for a change in society "to limit the influence of the alcohol industry and make the message unequivocal that less use of a toxin and carcinogen (even at very low levels) is better for health."

A full listing of the USPSTF members' and the editorialists' relevant financial relationships is available on the JAMA website.

JAMA. Published online November 13, 2018. USPSTF recommendation statement, Full text; Evidence report, Full text; McCarty et al, Editorial; Bazzi and Saitz, Editorial

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