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What Do We Do When the Alcohol Screen Is Positive?

Am Fam Physician. 2003 Feb 1;67(3):638-639.

Primary care physicians are frequently exhorted to screen patients for excessive alcohol use. The expert consensus is that use of a rapid screen (such as AUDIT, the Alcohol Use Disorders Identification Test) followed by a brief, focused intervention can effectively modify drinking behavior. The studies supporting this advice stress the importance of the physician-patient relationship in enabling patients to change and assume that primary care physicians are comfortable and proficient in working with these patients. Before this advice can be widely applied, much more must be learned about the difficulties faced by physicians in screening for alcohol misuse. Beich and colleagues studied the experience of Danish physicians to assess the impact on physicians of screening for excessive alcohol use in primary care and the practical issues related to it.

They interviewed 24 of 39 Danish general practitioners who volunteered to conduct an eight-week alcohol screening program in their practices from 1997 to 1998. During the project, the physicians administered AUDIT to 6,897 patients aged 18 to 64 years. More than 1,000 (15.8 percent) patients were identified as excessive drinkers, and 181 (2.6 percent) were suspected of alcohol dependency. Of patients found to drink excessively, more than 900 were randomly assigned to receive brief intervention or act as control subjects. Sixty-one percent of these patients responded to follow-up appointments after one year. The researchers conducted focus groups and personal interviews with the physicians before the results of the alcohol screening study were known. The interview and focus group sessions followed a semi-structured format. Analysis was based primarily on audiotape recordings of the sessions.

Most of the doctors were surprised by the large number of young people with hazardous drinking habits. They reported discomfort in screening young people and a preference that this take place in community settings rather than physician offices and be conducted at an earlier age. Most doctors were convinced that not all patients responded honestly to the screening questions, and almost all experienced negative reactions from some patients. Nevertheless, the few negative reactions were outweighed by positive reactions from most patients who reported that screening indicated exceptional concern for their well-being. The doctors found it difficult to follow up on interventions once drinking problems had been identified. Some physicians questioned their ability to effectively assist patients with lifestyle issues.

The authors conclude that although physicians recognize the importance of screening for alcohol misuse, even highly motivated physicians find this screening to be difficult and are often inconsistent or ambivalent about acting on screening results. The physicians experienced significant stress during the program because it disrupted their normal patterns of practice and frequently caused difficulties in the physician-patient relationship. The authors emphasize that recommendations about lifestyle interventions by primary care physicians need to be thoroughly tested in real practices. Inappropriately enthusiastic campaigns based on research situations can be ineffective in family practices and may lead to a sense of failure on the part of family physicians.

Beich A, et al. Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners BMJ. October 19, 2002;325:870–6.

editor's note: At last, someone has studied putting prevention theory into practice. The finding that the results of pilot studies are rarely replicated in real practice comes as no great surprise. Studies usually involve short, energetic campaigns in highly selected situations. Conversely, in-practice screening requires sustained, thorough efforts and, as shown by this study, can disrupt relationships and exhaust even the most dedicated physicians. Perhaps now we can have fewer “experts” blaming family physicians for inadequate performance on health promotion and earn greater respect for the complex, difficult job we try to do every day to promote good health.—A.D.W.

 

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