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Am Fam Physician. 2019;99(12):771-772

Related editorial: Identification of and Treatment for Unhealthy Alcohol Use in Primary Care Settings

Author disclosure: No relevant financial affiliations.

Case Study

A 20-year-old male with a history of exercise-induced asthma presents to your office for his yearly physical. He is a student at the local university and is on the university fencing team. When asked about his classwork, he expresses that college is going okay but can be stressful sometimes, noting that he occasionally misses classes in the morning because he is tired. He states that he spends time with friends to relieve stress, occasionally going to parties.

Case Study Questions

1. Based on the U.S. Preventive Services Task Force (USPSTF) recommendation statement, which one of the following is the initial screening test of choice for alcohol use in this patient?

  • A. Alcohol Use Disorders Identification Test (AUDIT).

  • B. AUDIT–Consumption (AUDIT-C).

  • C. No screening.

  • D. Cut down, Annoyed, Guilty, Eye-Opener (CAGE) tool.

  • E. USAUDIT-C (based on U.S. standards).

2. According to the USPSTF, which of the following tools are common components of effective brief behavioral counseling interventions?

  • A. General feedback.

  • B. Personalized normative feedback sessions.

  • C. Drinking diaries.

  • D. Web-based interventions.

3. The patient's 15-year-old brother presents to your office a week later for a sports team physical examination. What is the USPSTF recommendation for this younger patient?

  • A. Screen for unhealthy alcohol use with a one- to three-item screening instrument.

  • B. Do not screen for unhealthy alcohol use.

  • C. There is insufficient evidence to recommend for or against screening for unhealthy alcohol use.

  • D. Screen for unhealthy alcohol use with a comprehensive, 10-item screening instrument.

Answers

1. The correct answer is B. The USPSTF recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older and providing patients who are engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use. The USPSTF found that one- to three-item screening instruments have the best accuracy for assessing unhealthy alcohol use in adults 18 years or older, including the AUDIT-C and the Single Alcohol Screening Question (SASQ), which is recommended by the National Institute on Alcohol Abuse and Alcoholism.1 AUDIT is a powerful tool when completing a more in-depth risk assessment; however, for screening purposes it is recommended to use tools that are shorter and have higher sensitivity (such as AUDIT-C and SASQ), followed by a tool with higher specificity (e.g., AUDIT). The CAGE tool is well known but detects only alcohol dependence rather than the full spectrum of unhealthy alcohol use. Some preliminary evidence supports that the USAUDIT-C (based on U.S. standards) may be more valuable in identifying college drinkers who are at risk; however, this evidence is based on one study, and more evidence is necessary to evaluate this screening tool.

2. The correct answers are A, B, C, and D. Behavioral counseling interventions for unhealthy alcohol use vary in their specific components, administration, length, and number of interactions.2 Most interventions involve providing general feedback to patients (e.g., how their drinking habits fit with recommended limits, how to reduce alcohol use). The most commonly reported intervention component was personalized normative feedback sessions, in which participants were shown how their alcohol use compares with that of others; more than half of the included trials and almost all trials in young adults used this technique. Most trials in young adults involved one or two in-person or web-based personalized normative feedback sessions in university settings. Personalized normative feedback was often combined with motivational interviewing or more extensive cognitive behavior counseling. Other cognitive behavior strategies, such as drinking diaries, action plans, alcohol use prescriptions, stress management, or problem-solving, were also commonly used. The USPSTF was unable to identify specific intervention characteristics or components that were clearly associated with improved outcomes.

3. The correct answer is C. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening and brief behavioral counseling interventions for alcohol use in primary care settings in adolescents 12 to 17 years of age.1 The USPSTF found no studies that directly evaluated whether screening for unhealthy alcohol use in primary care settings in adolescents leads to reduced unhealthy alcohol use; improves risky behaviors; or improves health, social, or legal outcomes. The USPSTF found inadequate evidence on the harms of screening and brief behavioral counseling interventions for alcohol use in adolescents.

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