Unhealthy Alcohol Use in Primary Care—The Elephant in the Examination Room

Unhealthy alcohol use is a serious public health challenge that requires full attention.¹ In its recommendation statement,² supported by an evidence report and systematic review,³ the US Preventive Services Task Force (USPSTF) “recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use (B recommendation).”² One in 8 adults in the United States reports unhealthy alcohol use.⁴ Unhealthy alcohol use includes “at-risk” alcohol use, defined by the National Institute on Alcohol Abuse and Alcoholism as alcohol use greater than 4 drinks per occasion or 14 drinks per week for men aged 21 to 64 years and 3 drinks per occasion or 7 drinks per week for women of all ages and for men 65 years or older. It also includes alcohol use disorder, defined by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) based on the presence of 2 or more of 11 criteria, such as loss of control of use and withdrawal symptoms.⁴ About 6% of US adults have drinking patterns and associated symptoms that are sufficiently severe to meet criteria for alcohol use disorder. Globally, 1 in 20 deaths are related to alcohol use.¹

The most recent USPSTF recommendation² is similar to its 2013 recommendation,⁵ which also endorsed screening and follow-up with brief behavioral counseling interventions for patients with at-risk alcohol use encountered in primary care. Notably, the 2018 recommendations replace alcohol misuse with unhealthy alcohol use and explicitly recommend screening in all pregnant women. Although the USPSTF recommendations represent best practice, patients often are seen in primary care for the consequences of unhealthy alcohol use, such as poorly controlled hypertension, not the alcohol use per se. Although patients are treated for their immediate problem, they often leave without clear plans to cut back or abstain from alcohol use and thus improve their health. Screening and the provision of evidence-based counseling for unhealthy alcohol use and medications, including those approved by the US Food and Drug Administration to address alcohol use disorder (ie, naltrexone, acamprosate, and disulfiram), are the exception, not the norm.^1,4,6 Screening, such as by the 3-item Alcohol Use Disorders and Identification Test-Consumption (AUDIT-C) screen,⁷ and brief behavioral counseling can be effective, but only if screening tools are used as designed and the recommendations followed. The questions in the AUDIT-C are straightforward: “How often do you have a drink containing alcohol?” “How many standard drinks containing alcohol do you have on a typical day?” ”How often do you have 6 or more drinks on 1 occasion?”

Although the USPSTF has replaced the term alcohol misuse with unhealthy alcohol use, the USPSTF recommendations also include terms such as alcohol abuse and alcohol dependence.² These terms are outdated (eg, the DSM-IV terms alcohol abuse and alcohol dependence do not appear in the DSM-5) and thus may contribute to confusion among clinicians and stigma for patients.⁸ Also, while it is an important addition to specify that “any alcohol use is considered unhealthy in pregnancy”² and to provide clear guidance about screening, the recommendations would have been further strengthened by providing guidance on other circumstances in which any alcohol use is unhealthy. For instance, patients with chronic viral infections (eg, hepatitis B, hepatitis C, and HIV) and cirrhosis should also be prioritized for screening and brief intervention. Moreover, abstaining from alcohol should be recommended for patients prescribed medications that may interact with alcohol, especially sedating medications such as prescription opioids, benzodiazepines, and medications for opioid use disorder. The Centers for Disease Control and Prevention has issued such guidance,⁹ although the USPSTF statement does not incorporate it.

The USPSTF recommendations are grounded in studies examining the efficacy of screening and brief intervention.^3,10 There is also an extensive literature that examines the effectiveness of screening and brief intervention in primary care. For example, work conducted in the Department of Veterans Affairs demonstrates that despite standardized electronic clinical reminders, AUDIT-C screening is variably implemented.¹¹ This study underscores the challenges to implementing reliable screening into routine clinical care and highlights the need for systematic strategies to address these challenges, such as staff training or patient self-administration of the screen.

Another difficulty is that the components of brief behavioral counseling interventions are not standardized in content, delivery, dose, or duration. For this reason, studies conducted in routine clinical settings have not found the same reductions in unhealthy alcohol use as those found in randomized clinical trials.^12,13 In primary care, brief interventions are often needed because of limited time and the need to address other health issues. The USPSTF recommendations, however, were based on studies that had a median of 30 minutes of contact time between patients and clinicians (range, 1-600 minutes); with most studies having a total of 2 hours of contact time.^2,3 Across multiple visits, such contact times could be realistic in primary care, but not in single visits.

Alcohol use contributes to many common health conditions, including obesity, diabetes mellitus, hypertension, and depression. By addressing alcohol use, such conditions may be more easily controlled and in some cases, even resolved. Most of the studies contributing to the USPSTF recommendations used a “Screening, Brief Intervention, and Referral to Treatment” (SBIRT) approach,² which is an evidence-based practice to identify and reduce unhealthy alcohol use. The brief intervention integrates personalized, normative feedback to enhance a patient’s motivation to change his or her behavior. This approach requires training for clinicians to deliver it. Thus, the web-based delivery tools that were used in 30% of the studies reviewed by the USPSTF² are particularly appealing.¹⁴ Brief interventions, however, have not been shown to benefit patients with alcohol use disorder; such patients would benefit most from medications coupled with brief counseling and advice from their physician regarding alcohol’s effect on their health or referral to specialty care.¹⁵

The USPSTF “review did not include treatment with medications because medications are used to treat severe [alcohol use disorder] and are not routinely used in screen-detected persons.”² Nonetheless, primary care physicians should focus on prevention of alcohol-related harms across the spectrum of alcohol use, including prescribing medications for alcohol use disorder when appropriate. Medications such as naltrexone, acamprosate, and disulfiram can easily be prescribed in primary care and do not require specific training. The strongest data are for naltrexone; to prevent 1 person from returning to heavy drinking the number needed to treat is only 12.¹⁶There is substantial room for improvement, however, because less than 10% of patients with an alcohol use disorder are prescribed effective medications.¹⁷ Such low adherence to clinical guidelines is not found for many other chronic health conditions with major public and individual health impact, such as diabetes mellitus.¹⁸Unhealthy alcohol use and alcohol use disorder should not be exceptions.Studies to address implementation challenges should inform the next iteration of the USPSTF recommendations as they relate to screening (eg, standardized AUDIT-C delivery) and brief intervention (eg, content), as well as prescribing of medications for alcohol use disorder (eg, clinician awareness). Development and evaluation of quality metrics and other strategies to provide incentives for reliable, comprehensive practices are needed. With so many patients presenting to primary care with consequences of unhealthy alcohol use, it is time to address the elephant in the examination room.

Corresponding Author: E. Jennifer Edelman, MD, MHS, Yale School of Medicine, 367 Cedar St, E.S. Harkness Memorial Hall, Bldg A, Ste 401, New Haven, CT 06510 (ejennifer.edelman@yale.edu).