On a fairly regular basis doctors fail to identify people with alcohol use disorders. This failure is often due to simply not asking the right questions. The consequences of such failure may be substantial, especially if the person has major surgery or develops a severe illness and then manifests acute alcohol withdrawal. Screening and brief intervention are tools that can help physicians and patients in addressing alcohol abuse issues. They are however under-utilized .
According to two surveys of physicians and patients, regarding screening and brief intervention for alcohol abuse:
• 94 percent of primary care physicians missed or misdiagnosed alcohol-abusing patients (that is, when presented with early symptoms of alcohol abuse in adult patients, the physicians failed to include substance abuse among the five diagnoses they offered).b
• 88 percent of physicians said they asked new outpatients whether they drank alcohol, but only 13 percent used a formal alcohol screening tool.a
• 19.9 percent of primary care physicians considered themselves “very prepared” to identify alcoholism.
• 54.8 percent of patients believed that physicians do not know how to detect addictions.
Studies regarding BRIEF INTERVENTION indicated:
• The majority of physicians said they usually or always recommend 12-step groups to problem-drinking patients.
• 53.7 percent of patients said their primary care physician did nothing about their substance abuse, 43 percent said their physician never diagnosed it, and 10.7 percent believed their physician knew about their addiction but did nothing about it.b
• 74.1 percent of patients said their primary care physician was not involved in their decision to seek treatment, and 16.7 percent said the physician was involved “a little.”
(Source: Friedmann et al. 2000; b National Center on Addiction and Substance Abuse 2000.)
Screening and brief intervention in alcohol use disorders, CAGE questionnaire.
The simplest tool is perhaps the CAGE questionnaire, composed of just four questions:
- Have you ever felt the need to CUT DOWN on your use of alcohol?
- Has anyone ANNOYED you by criticizing your use of alcohol?
- Have you ever felt GUILTY because of something you’ve done while drinking?
- Have you ever taken a drink (EYE OPENER ) to steady your nerves or get over a hangover?
If two or more of the CAGE questions are answered ‘Yes’, it implies a high likelihood that the person abuses alcohol, or is an alcoholic; there are very few false positives.
Screening for Alcohol Abuse
Another tool to help diagnose alcohol abuse is to inquire about the history of drinking, amounts, frequency, patterns, and possible withdrawal symptoms (can appear 6-12 hours after alcohol stopped); Some of the mild withdrawal symptoms include:
- Insomnia and fatigue
- Mild anxiety/feeling nervous
- Mild restlessness/agitation
- Nausea and vomiting
- Excessive sweating
- Craving for alcohol
Levels of screening and brief intervention
Michael F. Fleming, M.D., M.P.H., a professor of family medicine at the University of Wisconsin Medical School, writes about the levels of screening and brief intervention that physicians should use to identify and address alcohol abuse problems:
Level 1 Screening
Clinicians under strict time constraints may have only enough time to ask a patient one screening question about alcohol consumption. One study (Taj et al. 1998) has shown that a positive response to the question “On any single occasion during the past 3 months, have you had more than 5 drinks containing alcohol?” accurately identifies patients who meet NIAAA criteria for at-risk drinking and those who meet the criteria for alcohol abuse and dependence specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (APA 1994).
Level 2 Screening
For clinicians who have time for more than one question, a series of questions recommended by NIAAA (2003) can reveal the patient’s frequency and level of alcohol use. These questions should be asked of all patients on an annual basis or in response to problems that may be alcohol related. They could be included in a pre-exam interview conducted as part of the patient’s check-in process.
• For all patients: Do you drink alcohol, including beer, wine, or distilled spirits?
• For current drinkers:
– On average, how many days per week do you drink alcohol?
– On a typical day when you drink, how many drinks do you have?
– What is the maximum number of drinks you had on any given day in the past month? (NIAAA 1995, 2003).
Patients who report binge drinking, male patients who report drinking more than 14 drinks per week, and female patients who have more than 7 drinks per week should receive brief intervention.
Level 3 Screening
If level 2 screening reveals that the patient may be at risk for alcohol-related problems, or if the clinician suspects that the patient is minimizing his or her alcohol use, the clinician may proceed to additional qualitative questions, which can reveal more information about the nature and extent of the problem. For example, the 10-question Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al. 1993) includes questions about the quantity and frequency of alcohol use, as well as binge drinking, dependence symptoms, and alcohol-related problems. It is more accurate than other screening methods in identifying at-risk drinking (Fiellin et al. 2000). Research has supported the accuracy of the AUDIT when used with women and minorities (Reinert and Allen 2002). This screening tool also has had promising results when tested with adolescents and young adults; it is less accurate with older patients, although further research is needed in these populations (Reinert and Allen 2002; Chung et al. 2000).
LEVELS of BRIEF INTERVENTION IN PRIMARY CARE
Brief intervention in primary care, like screening, can be simple and short or more extensive, possibly including referral to a substance abuse specialist. The level of intervention needed for a particular patient depends on the severity of the patient’s alcohol abuse or dependence, whether the patient also uses tobacco or illicit drugs or has co-occurring medical or psychiatric conditions, as well as on the clinical setting, the clinician’s skills and level of interest, and the time available. Clinicians with limited time may want to use a level 1 intervention for all patients who use alcohol above recommended limits and refer those patients who do not respond to a level 1 intervention to an alcohol treatment specialist at the followup visit.
Level 1 Brief Intervention
The most basic level of brief intervention consists of a simple statement or two. This level is strictly physician centered. The clinician states simply that he or she is concerned about the patient’s drinking, that it exceeds recommended limits and could lead to alcohol-related problems. The clinician also makes a recommendation that the patient minimize or stop drinking (WHOBISG 1996).
Level 2 Brief Intervention
This level of brief intervention involves two brief face-to-face sessions scheduled 1 month apart, with a followup telephone call 2 weeks after each session. This intervention was studied in Project TrEAT (Trial for Early Alcohol Treatment), a large-scale clinical trial conducted in primary care practices, and found to be effective up to 4 years later (Fleming et al. 2002). Patients in the intervention group reported reduced alcohol use, fewer days of hospitalization, and fewer emergency department visits compared with control group patients. This intervention may be especially useful with patients who are experiencing alcohol-related harm but who do not necessarily need referral to a specialist and may not need to stop drinking completely.
Level 3 Brief Intervention
A more extensive level of brief intervention that takes 15 to 20 minutes, a level 3 intervention can be administered by a primary care clinician or an office-based therapist. It may involve the use of strategies to increase a patient’s motivation to change his or her alcohol use, such as providing feedback about the negative consequences of the patient’s drinking and the risks of further problems, as well as information about the potential benefits of abstinence. This type of intervention often is used with patients who have symptoms of alcohol abuse or dependence, for whom abstinence may be the primary goal. Referral to a specialist is often a component of this type of intervention.
RESEARCH ON THE EFFECTIVENESS OF BRIEF INTERVENTION
Research has established the effectiveness of brief intervention in decreasing alcohol consumption among both male and female primary care patients, and among older and younger adults (Whitlock et al. 2004). Interventions that involve repeated contact generally are more effective than single-contact interventions (Whitlock et al. 2004). A review of studies reported that intervention participants reduced their alcohol consumption an average of 13 percent to 34 percent compared with the control group (USPSTF 2004). In addition, a recent meta-analysis concluded that brief interventions can reduce mortality rates among problem drinkers by an estimated 23 to 26 percent (Cuijpers et al. 2004). Most studies of brief intervention have been conducted in primary care practices, thus establishing that tightly controlled clinical settings are not necessary to show the positive results of this type of intervention.”
It is of primary importance for physicians to become well trained in the area of substance abuse. Screening and brief intervention for alcohol use disorders needs to become an integral part of primary patient care.