On Nov. 13, the U.S. Preventive Services Task Force (USPSTF) posted a final recommendation statement(www.uspreventiveservicestaskforce.org) and final evidence summary(www.uspreventiveservicestaskforce.org) on screening for and providing behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults.
Based on its review of the evidence, the USPSTF recommended primary care clinicians screen adults 18 and older, including pregnant women, for unhealthy alcohol use. If patients are found to be engaged in risky or hazardous drinking, clinicians should provide them with brief behavioral counseling interventions to reduce unhealthy alcohol use. This is a "B" recommendation.(www.uspreventiveservicestaskforce.org)
"In this final recommendation, the task force is calling on clinicians to screen all adults and provide counseling to those who drink beyond recommended limits," said USPSTF member Carol Mangione, M.D., M.S.P.H., in a news release.(www.uspreventiveservicestaskforce.org) "We found that screening and brief counseling in primary care can help reduce unhealthy alcohol use. Addressing this issue among pregnant women is especially important since alcohol use in pregnancy can lead to birth defects and developmental problems."
Task force members said current evidence is insufficient to assess the balance of benefits and harms of screening and providing behavioral counseling interventions in primary care settings for patients ages 12-17 -- an "I" statement.
"We continue to call for more research and encourage primary care clinicians to use their judgment when deciding whether to screen adolescents," said USPSTF Chair Sue Curry, Ph.D., in the release.
The task force defined unhealthy alcohol use as drinking beyond limits recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA):(www.niaaa.nih.gov)
- for men, no more than four drinks per day and no more than 14 drinks per week, and
- for women, no more than three drinks per day and no more than seven drinks per week.
- The U.S. Preventive Services Task Force has recommended that primary care clinicians screen all adults, including pregnant women, for unhealthy alcohol use.
- If patients are found to be engaged in risky or hazardous drinking, clinicians should provide brief behavioral counseling interventions to reduce unhealthy alcohol use.
- The task force said current evidence is insufficient to assess the balance of benefits and harms of screening and providing behavioral counseling interventions for patients ages 12-17.
Screening entails physicians asking patients a series of questions about how often they drink and other drinking patterns. If patients are found to engage in risky or hazardous drinking, physicians should provide brief behavioral counseling interventions to reduce unhealthy alcohol use, said the task force. These brief interventions typically include discussing how the patients' drinking compares to recommended limits and ways to reduce drinking.
Patients who appear to have a more severe alcohol use disorder (AUD) may be referred for more extensive treatment.
This final recommendation statement is consistent with the USPSTF's June draft recommendation and its 2013 final recommendation,(www.uspreventiveservicestaskforce.org) which the AAFP supported at the time.
In its 2013 recommendation, the task force used the term "alcohol misuse" to define a wide range of drinking behaviors (e.g., risky or hazardous alcohol use, harmful alcohol use, and alcohol abuse or dependence). However, in the current final recommendation, the USPSTF uses the American Society of Addiction Medicine's term "unhealthy use," which is defined as any use of alcohol that increases the risk of health consequences or has already led to health consequences, including an AUD diagnosis.
Final Recommendation Details
The USPSTF commissioned a systematic evidence review to update its 2013 recommendation on this type of screening. The review examined the effectiveness of screening to reduce unhealthy alcohol use, morbidity, mortality or risky behaviors, and to improve health, social or legal outcomes.
The task force also assessed the accuracy of various screening approaches, the effectiveness of counseling interventions to reduce unhealthy alcohol use and improve patient outcomes, and the harms of screening and behavioral counseling interventions.
As for screening tools, the USPSTF determined that one- to three-item screening instruments are the most accurate to assess unhealthy alcohol use in adults. Such instruments include the abbreviated Alcohol Use Disorders Identification Test-Consumption and the NIAAA-recommended Single Alcohol Screening Question. The task force discounted use of the well-known CAGE (Cut down, Annoyed, Guilty, Eye-opener) tool because it detects only alcohol dependence and not the full spectrum of unhealthy alcohol use.
Screening tools are available for specific populations, including for pregnant women, the task force noted, and any positive screen should be followed up with more in-depth assessment to confirm unhealthy alcohol use and determine next steps.
The USPSTF also found that behavioral counseling interventions for unhealthy alcohol use varied in their specific components, administration, length and number of interactions. Nearly all interventions included four or fewer sessions, with a median of one session. Most interventions consisted of two hours of contact time or less, with a median time of contact of 30 minutes.
Response to Public Comment
The draft version of this recommendation statement was posted for public comment on the USPSTF's website from June 5 to July 2.
Some commenters said they were concerned about the lack of discussion of specific populations.
In response, the USPSTF added language about the harms of alcohol consumption in adolescents to the Clinical Considerations(www.uspreventiveservicestaskforce.org) section and the harms of alcohol use during pregnancy to the Discussion(www.uspreventiveservicestaskforce.org) section.
Other commenters asked for clarification on which screening tools were being discussed, so the task force added a "Useful Resources" subhead in the Clinical Considerations section with references to further explain the tools.
The AAFP's Commission on Health of the Public and Science plans to review the USPSTF's final recommendation statement and evidence review and determine the Academy's stance on the recommendation.
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