What's New from the USPSTF

Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

This series of fact sheets is based on the work of the U.S. Preventive Services Task Force (USPSTF). The USPSTF systematically reviews the evidence of effectiveness of a wide range of clinical preventive services—including screening, counseling, and chemoprevention (the use of medication to prevent diseases)—to develop recommendations for preventive care in the primary care setting.

This fact sheet presents highlights of USPSTF recommendations on this topic and should not be used to make treatment or policy decisions. More detailed information on this subject is available from the USPSTF.

What Does the USPSTF Recommend?

The USPSTF recommends screening and behavioral counseling to reduce alcohol misuse by adults, including pregnant women, in primary care settings. The USPSTF concludes the evidence is insufficient to recommend for or against screening and behavioral counseling interventions to prevent or reduce alcohol misuse by adolescents in primary care settings.

What Is Alcohol Misuse?

Alcohol misuse refers to drinking in amounts or under circumstances that place people at risk for negative short- or long-term consequences, including increased risk for:

• Accidents.
• Injuries.
• Social and health problems.
• Death.

Alcohol misuse is drinking behavior that is often labeled as "risky," "hazardous," or "harmful." Risky or hazardous drinking is often defined by the quantity and frequency of drinking and by the fact that it places people at risk for a range of negative consequences. Risky or hazardous drinking is defined in the United States as more than 7 drinks per week or more than 3 drinks per occasion for women, and more than 14 drinks per week or more than 4 drinks per occasion for men. "Harmful drinking" refers to drinking by those who are currently experiencing physical, social, or psychological harm from alcohol use but whose drinking does not meet diagnostic criteria for dependence as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

How Effective Are Screening and Counseling for Alcohol Misuse in the Primary Care Setting?

Screening adults in primary care settings can accurately identify patients who misuse alcohol. Brief behavioral counseling with followup produces small to moderate reductions in alcohol consumption that are sustained for 6 to12 months or longer. There is limited evidence evaluating the effectiveness of screening and behavioral counseling to prevent or reduce alcohol misuse by adolescents in primary care settings.

What Are Effective Screening and Counseling Interventions?

There are several effective screening tools available to clinicians to assess the risk for alcohol-related problems:

• The Alcohol Use Disorders Identification Test (AUDIT), a 10-item screening questionnaire, is a sensitive tool for the detection of alcohol misuse and can be used alone or be embedded in broader health risk or lifestyle assessments.
• The TWEAK, a 5-item scale, and the T-ACE, a 4-item risk assessment questionnaire, are designed to screen pregnant women for risky drinking, harmful drinking, and alcohol use disorders.
• The 4-item CAGE (feeling the need to Cut down, Annoyed by criticism, Guilty about drinking, and need for an Eye-opener in the morning), perhaps the best-known screening test for use in the primary care setting, is intended to screen for alcohol abuse or dependence rather than for alcohol misuse.

These and other screening tools are available at the National Institute on Alcohol Abuse and Alcoholism Web site: www.niaaa.nih.gov/publications/instable.htm.

Effective counseling interventions to reduce alcohol misuse include an initial counseling session of up to 15 minutes, plus feedback, advice, and goal-setting. Most also include further assistance and followup. They can be delivered wholly or in part in the primary care setting, and by one or more members of the health care team, including physicians and non-physician practitioners.

Effective screening and counseling for alcohol misuse in the primary care setting may include the following steps:

• Assess alcohol consumption with a brief screening tool followed by clinical assessment as needed.
• Advise patients to reduce alcohol consumption to moderate levels.
• Agree on individual goals for reducing alcohol use or abstinence (if indicated).
• Assist patients with acquiring the motivations, self-help skills, or supports needed for behavior change.
• Arrange followup support and repeated counseling, including referring alcohol dependent drinkers for specialty treatment.

Although there was limited direct evidence for the effectiveness of counseling interventions in pregnant women, clinicians should inform all pregnant women and those contemplating pregnancy of the harmful effects of alcohol. Because safe levels of alcohol consumption during pregnancy are unknown, pregnant women should be advised to abstain from drinking alcohol.

How Can Clinicians Deliver Effective Interventions in the Primary Care Setting?

Resources that help clinicians deliver effective interventions include brief provider training or access to specially trained primary care practitioners or health educators, and the presence of office-level systems supports such as prompts, reminders, counseling algorithms, and patient education materials.

What Are the Harms of Screening and Counseling?

Two potential harms of screening and counseling for alcohol misuse include a possible reduction in the benefits of moderate drinking and under-treatment of drinkers with alcohol abuse or dependence who are guided toward moderate drinking rather than abstinence. The USPSTF found no data for either of these potential harms.

For More Information

Contact the following organizations:

healthfinder®
www.healthfinder.gov

National Institute on Alcohol Abuse and Alcoholism
www.niaaa.nih.gov

More detailed information is available in Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use: Systematic Evidence Review for the U.S. Preventive Services Task Force and in the USPSTF Recommendation Statement, Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse, which can be found on the Agency for Healthcare Research and Quality (AHRQ) Web site (www.preventiveservices.ahrq.gov) and through the National Guideline Clearinghouse™ (www.guideline.gov).

The Summary of Evidence and the USPSTF Recommendation Statement are also available in print through the AHRQ Clearinghouse (1-800-358-9295, or ahrqpubs@ahrq.gov).

Members of the USPSTF

The USPSTF is an independent panel of experts who represent the fields of family medicine, gerontology, obstetrics-gynecology, pediatrics, nursing, prevention research, and psychology. Members of the USPSTF when its recommendation on this topic was finalized:

Alfred O. Berg, M.D., M.P.H., Chair
Janet D. Allan, Ph.D., R.N., C.S., Vice-chair
Paul S. Frame, M.D.
Charles J. Homer, M.D., M.P.H.
Mark S. Johnson, M.D., M.P.H.
Jonathan D. Klein, M.D., M.P.H.
Tracy A. Lieu, MD, M.P.H.
C. Tracy Orleans, Ph.D.
Jeffrey F. Peipert, M.D., M.P.H.
Nola J. Pender, Ph.D., R.N.
Albert L. Siu, M.D., M.S.P.H.
Steven M. Teutsch, M.D., M.P.H.
Carolyn Westhoff, M.D., M.Sc.
Steven H. Woolf, M.D., M.P.H.

For a list of current Task Force members, go to www.ahrq.gov/clinic/uspstfab.htm

Current as of April 2004

Internet Citation:

Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse. What's New from the USPSTF. April 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/alcohol/alcomiswh.htm

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