New guidelines from the U.S. Preventive Services Task Force (USPSTF), published in the Journal of the American Medical Association (JAMA) on November 13, recommend that primary care physicians screen adults age 18 and older, including pregnant women, for unhealthy alcohol use. The task force declined to update the recommendations for adolescents ages 12 to 17, concluding that, “the evidence is insufficient to determine the benefits and harms of screening,” for the younger population.
What’s Considered Unhealthy Alcohol Use?
Unhealthy alcohol use covers a spectrum of behaviors that range from occasional risky drinking to alcohol use disorder (AUD), which is defined as harmful alcohol use or dependence. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines “risky use” as drinking more than the recommended limit of 4 drinks per day or 14 drinks per week for healthy men ages 21 to 64 or 3 drinks per day or 7 drinks per week for all adult women of any age and men 65 and over. A standard drink is defined as one 12-ounce beer with 5 percent alcohol content; one 5-ounce glass of wine with 12 percent alcohol content; or 1.5 ounces of liquor with 40 percent alcohol content.
U.S. Alcohol Use Is a Growing Health Concern
Drinking to excess is one of the most common causes of early death in the United States. On the basis of figures from the Centers for Disease Control and Prevention (CDC) from 2006 and 2010, it’s estimated that 88,000 alcohol-attributed deaths occurred every year. This figure includes everything from car crashes that occurred while drivers were under the influence of alcohol to chronic conditions like cirrhosis (alcohol-related liver disease). Beyond the cost to human life, there are financial impacts as well. According to a study published in the American Journal of Preventive Medicine, excessive alcohol use cost the United States an estimated $249 billion in lost workplace productivity, healthcare expenses, criminal justice expenses, and car accidents in just one year (2010). The task force cited research that suggests unhealthy drinking is on the rise in this country. A September 2017 study of college drinking published in the journal JAMA Psychiatry revealed that high-risk drinking increased by almost 30 percent between 2001–2002 and 2012–2013. In 2016, more than 1 out of 4 adults reported binge-drinking episodes.
What Do These New Recommendations Mean?
The U.S. Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. Its role is to improve health outcomes by making evidence-based recommendations about clinical preventive services. In this case, a preventive service is something doctors should ask about and follow up on as part of a routine visit, even if the person doesn’t exhibit signs or symptoms of the condition. The task force bases its recommendations on the existing evidence of the potential health benefits versus any potential negative impact that may result from the service. The cost of providing the service is not a consideration when determining recommendations. An existing example of this would be tobacco smoking: The USPSTF recommends that all clinicians ask all adults if they use tobacco and counsel them to stop if they do. According to the task force, short surveys of one to three questions have the best accuracy for assessing alcohol use, including the abbreviated Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) and the Single Alcohol Screening Question (SASQ). Frequency of alcohol use, typical amount of alcohol use and occasions of heavy use are part of the AUDIT-C. The SASQ asks, “How many times in the past year have you had five drinks [for men] or four drinks [for women and men over 65] in a day?” The task force reported the most common behavioral counseling included both face-to-face and web-based interventions. Interventions included the following strategies:
Feedback on how the individual’s drinking compared with recommended limitsFeedback comparing individual’s alcohol use with that of othersKeeping a drinking diary that tracks alcohol consumptionAction plansStress managementProblem-solving strategies that don’t include consuming alcohol
Consensus on Adults but Not Adolescents
The recommendations for adults are in line with those of the U.S. Surgeon General, the NIAAA, the CDC and the American Society for Addiction Medicine. The biggest difference in comparing the overall recommendation with other medical professional societies is that the task force declined to include adolescents in the guidelines, said a task force member, Carol M. Mangione, MD, in an interview with JAMA. The American Academy of Pediatrics (AAP) recommends screening all adolescent patients for alcohol use with a formal, validated screening tool. “That’s a big difference between our recommendation and the one the AAP has, but for adults, our recommendations are really quite aligned with all of the other professional organizations,” said Dr. Mangione. The insufficient evidence the task force cited in declining to change recommendations for adolescents is largely due to a dearth of studies performed in that population, says Sharon Levy, MD, MPH, the co-author of an editorial on the topic published in JAMA Pediatrics on November 14. “There are significant challenges to studying screening and brief intervention in adolescents,” she says, adding that it is both expensive and logistically difficult to study this issue in young people in the typical way that adults are analyzed. The recommendation for screening unsafe alcohol use is appropriate and valuable, says Gregory Price, MD, a family medicine doctor in Charlotte, North Carolina. The challenge is to fit all the recommendations for screening into an already full visit that not only includes any concerns the patient has, but also questions about tobacco use, BMI, depression, seat belts, and sexual health, as well as covering any screening exams that may be due, such as a colonoscopy or mammogram. “To cover these issues and more in the framework of a 30-minute new patient visit can be daunting,” he says. This can be especially hard if the person tests “positive” for more than one screening, such as depression, as this is an extremely important condition to address but also complex.
