Alcohol-related problems, which cause substantial morbidity (1) and mortality, (2) are common: 14.8% of U.S. adults have engaged in at least one episode of heavy drinking (>5 drinks) in the previous 30 days, (3) and 7.4% have a diagnosable past-year alcohol use disorder. (4) They are also treatable. In efficacy trials, brief interventions by primary care physicians helped 40% of hazardous drinkers reduce their drinking to safe levels, compared with 20% in control groups. (5-7)
Screening for alcohol problems can be accomplished quickly and, for both patients and physicians, comfortably. Many screening instruments have been validated, including the four-question CAGE, (8) the ten-item Alcohol Use Disorders Identification Test, (9-11) and a single question ("When was the last time you had more than 4 drinks [5 if male] in one day?"). (12) In a study comparing the CAGE and the single question, physicians were more likely to use the single question, but there were no other significant differences between those two approaches. (13)
In the successful clinical trials, brief interventions have typically taken two 10 to 15 minute office visits. (5-7) Integrating them into daily practice is therefore challenging. Primary care office visits are short but face complex agendas. Furthermore, physicians value a patient-centered approach to care which will include a discussion of alcohol only if the patient brings it up (which is uncommon) or there is a clear indication to do so (e.g., intoxication).
The same issues can be raised, for example, with hypertension. Patients with no prior history of hypertension seldom present specifically to discuss it. Primary care practices instead have systems that routinely screen for it. When it's found, the physician and patient briefly discuss it, arrange to gather further information (e.g., home blood pressure measurement, lab studies), and schedule a follow-up visit to address it more fully. The same approach can be used for alcohol problems.
Given the prevalence of alcohol use disorders and their contribution to patient morbidity and mortality, it makes sense for family physicians to screen for this problem.
Brief Alcohol Screening and Intervention in Family Medicine
Rationale for Screening and Brief Intervention for Alcohol Problems in Primary Care
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- Buchsbaum DG, Buchanan RG, Center RM, Schnoll SH, Lawton MJ. Screening for alcohol abuse using CAGE scores and likelihood rations. Ann Intern Med. 1991;115:774-777.
- Reinert DF, Allen JP. The Alcohol Use Disorders Identification Test (AUDIT): a review of recent research. Alcohol Clin Exp Res. 2002;26(2):272-279.
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- Babor TF, Higgins-Biddle JC, Saunders JB, Monteior MG. The Alcohol Use Disorders identification Test: guidelines for use in primary care. 1-35. 2001. Geneva, Switzerland, World Health Organization.
- Williams RH, Vinson DC. Validation of a single question screen for problem drinking. J Fam Pract. 2001;50(4):307-312.
- Vinson DC, Galliher JM, Reidinger C, Kappus JA. Comfortably Engaging: Which approach to alcohol screening should we use? Annals of Family Medicine. In press 2004.
