Final Recommendation Statement
Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care, May 2013
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Summary of Recommendations and Evidence
|Adults aged 18 and older|
The USPSTF recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse
|The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.|
|Adolescents (under 18 years of age)|
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening and behavioral counseling interventions in primary care settings to reduce alcohol misuse in adolescents.
|The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.|
The USPSTF uses the term “alcohol misuse” to define a spectrum of behaviors, including risky or hazardous alcohol use (for example, harmful alcohol use and alcohol abuse or dependence). Risky or hazardous alcohol use means drinking more than the recommended daily, weekly, or per-occasion amounts resulting in increased risk for health consequences. For example, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the U.S. Department of Agriculture define “risky use” as consuming more than 4 drinks on any day or 14 drinks per week for men, or more than 3 drinks on any day or 7 drinks per week for women (as well as any level of consumption under certain circumstances)1, 2. “Harmful alcohol use” (defined by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision) is a pattern of drinking that causes damage to physical or mental health3.
“Alcohol abuse” (defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) is drinking that leads an individual to recurrently fail in major home, work, or school responsibilities; use alcohol in physically hazardous situations (such as while operating heavy machinery); or have alcohol-related legal or social problems4. “Alcohol dependence” (or alcoholism) (defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) includes physical cravings and withdrawal symptoms, frequent consumption of alcohol in larger amounts than intended over longer periods, and a need for markedly increased amounts of alcohol to achieve intoxication4.
An estimated 30% of the U.S. population is affected by alcohol misuse, and most of these persons engage in risky use. More than 85,000 deaths per year are attributable to alcohol misuse; it is the estimated third leading cause of preventable deaths in the United States5, 6.
The USPSTF found adequate evidence that numerous screening instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity.
Benefits of Detection and Behavioral Counseling Interventions
The USPSTF found adequate evidence that brief behavioral counseling interventions are effective in reducing heavy drinking episodes in adults engaging in risky or hazardous drinking. These interventions also reduce weekly alcohol consumption rates and increase adherence to recommended drinking limits. Direct evidence about the effectiveness of brief behavioral counseling interventions in pregnant women engaging in alcohol use is more limited. However, studies in the general adult population show that such interventions reduce alcohol consumption and increase adherence to recommended drinking limits among women of childbearing age.
The USPSTF found insufficient evidence on the effect of screening for alcohol misuse and brief behavioral counseling interventions on outcomes in adolescents.
Harms of Detection and Behavioral Counseling Interventions
There are minimal data to assess the magnitude of harms of screening for alcohol misuse or of consequent brief behavioral counseling interventions in any population. However, no studies have identified direct evidence of harms. Thus, given the noninvasive nature of the screening process and behavioral counseling interventions, the related harms are probably small to none.
The USPSTF concludes with moderate certainty that there is a moderate net benefit to screening for alcohol misuse and brief behavioral counseling interventions in the primary care setting for adults aged 18 years or older.
The evidence on screening for alcohol misuse and brief behavioral counseling interventions in the primary care setting for adolescents is insufficient, and the balance of benefits and harms cannot be determined.
Patient Population Under Consideration
The B recommendation applies to adults aged 18 years and older, and the I statement applies to adolescents aged 12 to 17 years. Although pregnant women are included, this recommendation is related to decreasing risky or hazardous drinking, not to complete abstinence, which is recommended for all pregnant women. These recommendations do not apply to persons who are actively seeking evaluation or treatment for alcohol misuse.
The USPSTF considers 3 tools as the instruments of choice for screening for alcohol misuse in the primary care setting: the Alcohol Use Disorders Identification Test (AUDIT), the abbreviated AUDIT-Consumption (AUDIT-C), and single-question screening (for example, the NIAAA recommends asking, “How many times in the past year have you had 5 [for men] or 4 [for women and all adults older than 65 years] or more drinks in a day?”).
Of available screening tools, AUDIT is the most widely studied for detecting alcohol misuse in primary care settings; both AUDIT and the abbreviated AUDIT-C have good sensitivity and specificity for detecting the full spectrum of alcohol misuse across multiple populations. AUDIT comprises 10 questions and requires approximately 2 to 5 minutes to administer; AUDIT-C comprises 3 questions and takes 1 to 2 minutes to complete. Single-question screening also has adequate sensitivity and specificity across the alcohol-misuse spectrum and requires less than 1 minute to administer.
Behavioral Counseling Interventions
Behavioral counseling interventions for alcohol misuse vary in their specific components, administration, length, and number of interactions. They may include cognitive behavioral strategies, such as action plans, drinking diaries, stress management, or problem solving. Interventions may be delivered by face-to-face sessions, written self-help materials, computer- or Web-based programs, or telephone counseling. For the purposes of this recommendation statement, the USPSTF uses the following definitions of intervention intensity: very brief single contact (≤5 minutes), brief single contact (6 to 15 minutes), brief multicontact (each contact is 6 to 15 minutes), and extended multicontact (≥1 contact, each >15 minutes). Brief multicontact behavioral counseling seems to have the best evidence of effectiveness; very brief behavioral counseling has limited effect5, 6.
The USPSTF found that counseling interventions in the primary care setting can positively affect unhealthy drinking behaviors in adults engaging in risky or hazardous drinking. Positive outcomes include reducing weekly alcohol consumption and long-term adherence to recommended drinking limits. Because brief behavioral counseling interventions decrease the proportion of persons who engage in episodes of heavy drinking (which results in high blood alcohol concentration [BAC]), indirect evidence supports the effect of screening and brief behavioral counseling interventions on important health outcomes, such as the probability of traumatic injury or death, especially that related to motor vehicles.
Although screening detects persons along the entire spectrum of alcohol misuse, trials of behavioral counseling interventions in primary care settings largely focused on risky or hazardous drinking rather than alcohol abuse or dependence. Limited evidence suggests that brief behavioral counseling interventions are generally ineffective as singular treatments for alcohol abuse or dependence. The USPSTF did not formally evaluate other interventions (such as pharmacotherapy or outpatient treatment programs) for alcohol abuse or dependence, but the benefits of specialty treatment are well-established and recommended for persons meeting the diagnostic criteria for alcohol dependence.
Evidence is lacking to determine the optimal interval for screening for alcohol misuse in adults.
Suggestions for Practice Regarding the I Statement
In deciding whether to screen adolescents for alcohol misuse and provide behavioral counseling interventions, primary care providers should consider the following factors.
Potential Preventable Burden
In 2010, approximately 14% of adolescents in the 8th grade and 41% in the 12th grade reported using alcohol at least once within the past 30 days; 7% and 23%, respectively, reported consuming at least 5 or more drinks on a single occasion (an episode of heavy use) within the previous 2 weeks7. Motor vehicle crashes are the leading cause of death for adolescents8; according to the Substance Abuse and Mental Health Services Administration, about 4% of 16-year-olds and 9% of 17-year-olds in 2009 drove under the influence of alcohol at least once during the previous year9. Thirty-seven percent of traffic deaths among youth aged 16 to 20 years involve alcohol, and these deaths frequently involve alcohol-impaired drivers with lower BACs than other age groups10.
Behavioral counseling interventions are associated with a time commitment ranging from 5 minutes to 2 hours, spread over multiple contacts. There are potential financial costs for parents and caregivers from lost work hours and travel to and from the provider.
Potential harms associated with screening for alcohol misuse include anxiety, stigma or labeling, and interference with the clinician-patient relationship. Although evidence is very limited, no direct harms were identified for any population in available studies.
Research suggests that although a majority of pediatricians and family practice clinicians report providing some alcohol prevention services to adolescent patients, they do not universally or consistently screen and counsel for alcohol misuse11. Barriers include a perceived lack of time, familiarity with screening tools, training in managing positive results, and available treatment resources12.
The AUDIT and AUDIT-C screening instruments for alcohol misuse are available from the Substance Abuse and Mental Health Services Administration-Health Resources and Services Administration Center for Integrated Health Solutions (www.integration.samhsa.gov/clinical-practice/screening-tools). Further details about the single-question screening method, as well as resources on primary care–feasible behavioral interventions, are available from the NIAAA (http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf).
The Community Preventive Services Task Force recommends electronic screening and brief intervention to reduce excessive alcohol consumption. Electronic screening and brief intervention uses electronic devices (for example, computers, telephones, or mobile devices) to facilitate screening for excessive drinking and delivering a brief intervention that provides personalized feedback about the risks and consequences of excessive drinking. Delivery of personalized feedback can range from fully automated (computer-based) to interactive (provided by a person over the telephone). At least one part of the brief intervention must be delivered by an electronic device. Electronic screening and brief intervention can be delivered in various settings, such as health care systems, universities, or communities. The Community Preventive Services Task Force found limited information on the effectiveness of electronic screening and brief intervention among adolescents.
The Community Preventive Services Task Force has also evaluated public health interventions (those that occur outside of the clinical practice setting) to prevent excessive alcohol consumption. It recommends instituting liability laws for establishments that sell or serve alcohol, increasing taxes on alcohol, maintaining limits on days and hours of the sale of alcohol, and regulating alcohol outlet density in communities as effective in preventing or reducing alcohol-related harms. It also recommends enhanced enforcement of laws prohibiting the sale of alcohol to minors. More information about the Community Preventive Services Task Force's recommendations on alcohol misuse is available at www.thecommunityguide.org/alcohol/index.html.
The Cochrane Collaboration has performed 2 systematic reviews to evaluate the effects of universal school- and family-based prevention programs to prevent or reduce alcohol misuse in young people. Although not entirely consistent across studies, evidence generally supported the effectiveness of certain school-based psychosocial and developmental programs, such as the Life Skills Training Program, the Unplugged Program, and the Good Behavior Game13. Similarly, evidence generally supported small but positive effects from family-based interventions in preventing alcohol misuse in young people14.
The USPSTF has made recommendations on screening for and interventions to decrease the unhealthy use of other substances, including illicit drugs and tobacco. More information can be found atwww.uspreventiveservicetaskforce.org.
Research Needs and Gaps
Alcohol misuse among adolescents is an important public health problem. Limited evidence is available to assess the effects of screening and behavioral counseling in adolescents, and high-quality studies specifically addressing this population are needed. Although there is adequate evidence that brief behavioral counseling interventions improve several intermediate outcomes for persons engaging in risky or hazardous drinking, there is little direct evidence describing the ultimate effect of these interventions on longer-term morbidity, mortality, or quality of life. Most trials of behavioral counseling for screening-detected alcohol misuse focused on risky or hazardous alcohol use; future research is needed to help explain whether persons engaging in harmful drinking or alcohol abuse might benefit from behavioral counseling interventions in the primary care setting. Finally, detailed information about the relative comparative effectiveness of specific behavioral counseling components or approaches is largely lacking, as is focused guidance on how to individualize treatment decisions for a given subpopulation.
Burden of Disease
Alcohol misuse is a common issue across U.S. primary care populations; approximately 21% of adults report engaging in risky or hazardous drinking15, and the prevalence of current alcohol dependence is about 4%16. Alcohol misuse plays a contributing role in a wide range of health conditions, such as hypertension, gastritis, liver disease and cirrhosis, pancreatitis, certain types of cancer (for example, breast and esophageal), cognitive impairment, anxiety, and depression17. Alcohol misuse has also been implicated as a major factor in morbidity and mortality as a result of trauma, including falls, drownings, fires, motor vehicle crashes, homicide, and suicide18. Alcohol use in pregnancy is linked to a pattern of developmental abnormalities known as fetal alcohol syndrome, which occurs in about 0.2 to 1.5 per 1,000 live births in the United States19.
Scope of Review
The USPSTF commissioned a systematic evidence review of randomized, controlled trials and nonrandomized trials with controls or comparators published between 1985 and 2011 on screening and behavioral counseling interventions for alcohol misuse in adults, adolescents, and pregnant women. The review also included individual systematic evidence reviews with or without meta-analyses done between 2006 and 2011. The following topics were examined: direct evidence of the effectiveness of screening for improving health outcomes, the accuracy of various screening approaches, the effectiveness of various behavioral counseling interventions for improving intermediate (such as rate of alcohol consumption or number of heavy drinking episodes) or long-term (such as alcohol-associated morbidity or mortality) health outcomes, the harms of screening and behavioral counseling interventions, and influences on the health care system that promote or detract from effective screening and counseling interventions for alcohol misuse.
Accuracy of Screening Tests
Numerous screening instruments can detect some or all of the drinking categories included in the spectrum of alcohol misuse. Tests include single-question screening; AUDIT; the Cut-Down, Annoyed, Guilty, and Eye-Opener (CAGE) questionnaire and related tests designed specifically for pregnant women, such as the Tolerance, Annoyed, Cut-Down, and Eye-Opener (T-ACE) and Tolerance, Worried, Eye-Openers, Amnesia, Kut-Down (TWEAK); the Michigan Alcoholism Screening Test; the Rapid Alcohol Problems Screen; and the Alcohol-Related Problems Survey, among others. Several of these tests also have abbreviated versions.
Five fair- to good-quality systematic reviews compared different screening test characteristics in primary care populations5, 6. Overall, the full AUDIT instrument, the abbreviated AUDIT-C, and single-question screening (asking, “How many times in the past year have you had 5 [for men] or 4 [for women and all adults older than 65 years] or more drinks in a day?”) have the best performance characteristics for detecting the full spectrum of alcohol misuse in adults, young adults, and pregnant women; therefore, the USPSTF prefers these screening approaches.
AUDIT shows an optimal balance of sensitivity and specificity for detecting all forms of alcohol misuse when cutoff points of 4 or more (sensitivity, 84% to 85%; specificity, 77% to 84%) or 5 or more (sensitivity, 70% to 92%; specificity, 73% to 94%) are used; use of higher cutoff points increases specificity to an extent but reduces sensitivity. The sensitivity and specificity of AUDIT-C are best balanced at cutoff points of 4 or more (74% to 76% and 80% to 83%, respectively) and 3 or more (74% to 88% and 64% to 83%, respectively). Single-question screening has a reported sensitivity of 82% to 87% and specificity of 61% to 79%5, 6. However, the sensitivity of these screening tests varies by sex and achieving similar sensitivity for women requires a cutoff 1 point lower than that for men. Although the CAGE questionnaire has frequently been used in primary care settings as a low-burden screening tool for alcohol disorders, it has comparatively poor sensitivity for identifying risky or hazardous drinking, particularly among older adults (14% to 39%) and pregnant women (38% to 49%)5.
None of the identified systematic reviews provided information about the use of screening tests in adolescents.
Effectiveness of Screening and Behavioral Counseling Interventions
None of the published studies directly evaluated the effect of screening and consequent behavioral counseling interventions for alcohol misuse compared with no screening on alcohol-related morbidity or mortality in any population. However, the USPSTF did find adequate evidence that brief counseling interventions in adults with screening-detected risky or hazardous drinking positively affect several unhealthy drinking behaviors, including heavy episodic (binge) drinking, high average weekly intake of alcohol, and consumption above recommended intake limits.
Twenty-three randomized, controlled trials (11 of which were performed in the United States) compared the effects of behavioral counseling interventions with usual care in adults with screening-detected alcohol misuse. Most interventions evaluated were either brief or brief multicontact behavioral counseling interventions that were directly provided by primary care physicians. The mean age of participants was generally between 30 and 50 years5, 6.
Studies show that behavioral counseling interventions reduce binge drinking. “Binge drinking” is heavy per-occasion alcohol use; the NIAAA defines it as a pattern of drinking that results in a BAC of 0.08% or higher, generally when men consume 5 or more drinks and women consume 4 or more drinks on 1 occasion within about 2 hours20. Meta-analysis from 7 trials showed that behavioral counseling interventions resulted in a 12% absolute increase in the proportion of adult participants with screening-detected risky or hazardous drinking who reported no heavy drinking episodes after 1 year compared with the control group (95% CI, 7% to 16%). Subgroup analyses suggest that single-contact interventions may be less effective or ineffective compared with multicontact approaches5, 6.
In younger adults (such as college age), 3 trials provided evidence that behavioral counseling interventions reduced the frequency of heavy drinking episodes by about 1 day per month (average baseline, 6 to 7 heavy drinking days per month) at 6 months of follow-up21-23. The evidence was insufficient to evaluate whether there are relative differences in the effect for older adults (aged 65 years or older).
Behavioral counseling interventions also reduce the total number of drinks per week consumed by adults with screening-detected risky or hazardous drinking. A standard drink is defined as 12.0 oz of beer, 5.0 oz of wine, or 1.5 oz of liquor. Meta-analysis of 10 trials reporting on this outcome showed that adults receiving behavioral counseling interventions reduced their average weekly consumption of alcohol from a baseline of 23 drinks to approximately 19 drinks per week at 12 months of follow-up compared with the control group (absolute difference, 3.6 fewer drinks per week [95% CI, 2.4 to 4.8])5, 6. Among younger adults, data from 3 trials conducted in the United States showed that average consumption decreased from a baseline of about 15 drinks to 13 drinks per week at 6 months of follow-up21-23. Two studies provided information about the effect of behavioral counseling on weekly alcohol consumption rates in older adults; pooled analysis showed that consumption decreased from an average of about 16 drinks to about 14 drinks per week at 12 months of follow-up24, 25.
On the basis of a meta-analysis of 9 relevant trials, the absolute proportion of adults with screening-detected risky or hazardous drinking who reported not exceeding recommended drinking limits over 12 months increased by 11% (95% CI, 8% to 13%) in participants receiving behavioral counseling interventions compared with the control group5, 6. The definition and rationale of a given recommended limit of alcohol consumption may vary to some degree across guidelines, making this outcome slightly more subjective than the others evaluated by the USPSTF.
A commonly cited standard developed by the NIAAA recommends that healthy adult men aged 65 years or younger have no more than 4 drinks per day and no more than 14 drinks per week and healthy adult women and all adults older than 65 years have no more than 3 drinks per day and no more than 7 drinks per week. The NIAAA also recommends lower levels of consumption or abstinence for adults who receive medications that interact with alcohol, have a health condition exacerbated by alcohol, or are pregnant26. For older adults (aged 65 years or older), 2 studies showed an absolute increase of 9% (95% CI, 2% to 16%) in the proportion of risky or hazardous drinkers who adhered to recommended drinking limits after behavioral counseling at 1 year of follow-up24, 25. There was not enough evidence to assess whether there are relative differences in the effect for younger adults.
A single study meeting inclusion criteria was identified for pregnant women. In this trial, 250 pregnant women with a gestational age of 28 weeks or less were randomly assigned to comprehensive assessment only or assessment and a 45-minute behavioral counseling intervention. The study found a sustained reduction in the daily consumption of alcohol in both groups (with no significant difference between them); it also found that women who abstained from alcohol at baseline in the behavioral intervention group were more likely to do so than women in the control group (86% vs. 72%; P = 0.04)27. Only 1 study meeting inclusion criteria included women who were breastfeeding28, and they made up less than 30% of the total population. However, as previously described, multiple studies in the general adult population showed that behavioral counseling interventions reduce alcohol consumption and increase adherence to recommended drinking limits among women of childbearing age.
No studies meeting inclusion criteria were identified for the effects of brief behavioral counseling interventions on screening-detected alcohol misuse in adolescents.
Few studies of behavioral counseling interventions for alcohol misuse have rigorously examined longer-term health outcomes, such as alcohol-related morbidity or mortality. Meta-analysis of 6 studies did not find a significant effect of behavioral counseling interventions on all-cause mortality (rate ratio, 0.52 [95% CI, 0.22 to 1.2]), although findings generally trended favorably for the intervention groups. However, because none of the studies were designed or powered to detect a difference in mortality, it is difficult to draw any firm conclusions about the true effect5, 6. A sizable body of observational evidence does show a link between increasing alcohol consumption levels and risk for traumatic injury or death.
A 2010 systematic review and meta-analysis of case–control and case-crossover studies evaluating the association between level of acute alcohol consumption and probability of an injury related to a motor vehicle crash found a rapidly increasing dose–response relationship between the 2 variables. For the consumption of 24 g of alcohol (or about 2 standard drinks) within a 6-hour period, the odds ratio of being injured in a motor vehicle crash is 2.20 compared with no alcohol intake; at 4 to 5 drinks consumed (a rough proxy for the NIAAA definition of a heavy drinking episode), the odds ratio is about 5.00 to 10.00, and after 10 drinks, the odds ratio is 52.0029. A review of case–control roadside surveys evaluating the relationship between BAC in drivers involved in motor vehicle crashes compared with those not involved in incidents found that the relative probability of a motor vehicle crash resulting in injury or death increased sharply after attainment of a BAC of about 0.08% (relative risk ranged from about 2 to 4 at a BAC of 0.08% compared with a BAC of 0.00%, with sharper increases at higher BACs)30.
Screening for alcohol misuse will detect persons engaging in a spectrum of unhealthy drinking behaviors, not just risky or hazardous drinking. However, most available studies of behavioral counseling interventions focused on risky or hazardous drinking and either specifically excluded persons with alcohol dependence or used enrollment criteria that necessarily restricted participation by such persons. The limited evidence available for persons with alcohol dependence suggests that brief behavioral counseling interventions may be ineffective in this population5, 6. The effectiveness of behavioral counseling in primary care settings for persons engaging in harmful alcohol use or alcohol abuse is uncertain.
Although the USPSTF did not formally assess the evidence on interventions for alcohol dependence, a range of treatment options with established efficacy exists, including 12-step programs (such as Alcoholics Anonymous), intensive outpatient or inpatient treatment programs, and pharmacotherapy. However, the relative effectiveness of the various treatment approaches has not been systematically examined in randomized trials and the USPSTF was unable to identify any trials of pharmacotherapy in the primary care setting.
Potential Harms of Screening and Behavioral Counseling
Very limited evidence is available on the harms of screening and behavioral counseling for alcohol misuse. Possible harms include anxiety, labeling, discrimination, or interference with the doctor–patient relationship. An additional effect might be a consequent increase in smoking or illicit substance use, if persons receiving screening or behavioral counseling interventions for risky drinking replace 1 harmful substance with another.
No studies directly evaluated the harms of screening; few studies reported information about harms resulting from behavioral counseling interventions. Two studies found no changes in anxiety levels among adults with screening-detected alcohol misuse receiving behavioral counseling, and 5 studies qualitatively described that cigarette consumption seemed unchanged among adults receiving counseling interventions5, 6. No specific information was available for the adolescent population. No direct evidence of harm from screening or behavioral counseling for alcohol misuse was identified in any study; given the noninvasive nature of these practices, the adverse effects are likely to be small to none.
Estimate of Magnitude of Net Benefit
Adequate evidence supports a moderate beneficial effect of screening for alcohol misuse followed by brief behavioral counseling interventions in adults engaged in risky or hazardous drinking. Unhealthy drinking behaviors in this population, including heavy episodic drinking, high daily or weekly levels of alcohol consumption, and exceeding recommended drinking limits, can all be reduced through screening and behavioral counseling in the primary care setting. Although limited specific evidence for pregnant women was found, the USPSTF determined that available studies of behavioral counseling interventions for alcohol misuse in the general adult population apply to pregnant adult women.
Available studies have not focused on the effect of screening and behavioral counseling on longer-term health outcomes, such as alcohol-related disease or death. However, epidemiologic evidence supports an association between increasing alcohol consumption and increased risk for morbidity and mortality related to a motor vehicle crash, providing indirect support that counseling interventions—which reduce acute and sustained alcohol intake levels—can help improve some health outcomes in alcohol misuse29, 30. A large body of observational evidence also links alcohol use in pregnant women with an increased risk for subsequent birth defects31, 32.
Given the noninvasive nature of screening and counseling interventions for alcohol misuse, the USPSTF assessed the range of probable harms to be small to none. Therefore, given moderate benefit and little to no associated harm, the USPSTF concludes with moderate certainty that the net benefit of screening adults, including younger adults, for alcohol misuse and providing brief behavioral counseling interventions for those engaged in risky or hazardous drinking is moderate.
No studies were identified that addressed screening and behavioral counseling interventions for alcohol misuse in adolescents. As such, the USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of screening and behavioral counseling for alcohol misuse in this population.
Response to Public Comments
A draft version of this recommendation statement was posted on the USPSTF Web site from 24 September 2012 to 22 October 2012. Several comments indicated that the USPSTF should more clearly emphasize the need for more research on screening and counseling interventions for alcohol misuse in the adolescent population; this was added to the Research Needs and Gaps section. Some comments requested the inclusion of recommended screening instruments; links to these tools were added to the Useful Resources section. Several comments indicated that there was insufficient explanation of the distinctions between risky drinking and alcohol dependence, as well as what constitutes “binge” drinking or a “drink”; expanded definitions and examples were added to the Rationale and Discussion sections.
Update of Previous Recommendation
This recommendation replaces the 2004 recommendation. In this update, the USPSTF has clarified that it defines alcohol misuse as encompassing the full spectrum of unhealthy drinking behaviors, from risky drinking to alcohol dependence, rather than limiting its meaning to just risky, hazardous, or harmful drinking (as screening will detect a broad range of unhealthy drinking behaviors). The USPSTF emphasizes, however, that evidence regarding the effectiveness of brief behavioral counseling interventions in the primary care setting remains largely restricted to persons engaging in risky or hazardous drinking.
Recommendations of Others
The American Society of Addiction Medicine recommends that primary care providers routinely screen for the presence of alcohol use problems in patients, screen for risk factors for development of alcohol dependence, and provide appropriate interventions33. The NIAAA encourages primary care clinicians to incorporate alcohol screening and interventions into their practices and provides specific tools to implement these activities26.
The American College of Obstetricians and Gynecologists states that obstetrician–gynecologists have a key role in screening and providing brief intervention, patient education, and treatment referral for their patients who drink alcohol at risk levels. For pregnant women and those at risk for pregnancy, it is important that obstetrician–gynecologists give compelling and clear advice to avoid alcohol use or provide assistance for achieving abstinence or effective contraception to women who require help34.
The American Academy of Pediatrics recommends that clinicians screen all adolescent patients for alcohol use with a formal, validated screening tool, such as the Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) substance abuse screening test, at every health supervision visit and appropriate acute care visits and respond to screening results with the appropriate brief intervention35.
Members of the U.S. Preventive Services Task Force
Members of the U.S. Preventive Services Task Force at the time this recommendation was finalized† are Virginia A. Moyer, MD, MPH, Chair (American Board of Pediatrics, Chapel Hill, North Carolina); Michael L. LeFevre, MD, MSPH, Co-Vice Chair (University of Missouri School of Medicine, Columbia, Missouri); Albert L. Siu, MD, MSPH, Co-Vice Chair (Mount Sinai School of Medicine, New York, and James J. Peters Veterans Affairs Medical Center, Bronx, New York); Linda Ciofu Baumann, PhD, RN (University of Wisconsin, Madison, Wisconsin); Kirsten Bibbins-Domingo, PhD, MD (University of California, San Francisco, San Francisco, California); Susan J. Curry, PhD (University of Iowa College of Public Health, Iowa City, Iowa); Mark Ebell, MD, MS (University of Georgia, Athens, Georgia); Glenn Flores, MD (University of Texas Southwestern, Dallas, Texas); Francisco A.R. García, MD, MPH (Pima County Department of Health, Tucson, Arizona); Adelita Gonzales Cantu, RN, PhD (University of Texas Health Science Center, San Antonio, Texas); David C. Grossman, MD, MPH (Group Health Cooperative, Seattle, Washington); Jessica Herzstein, MD, MPH (Air Products, Allentown, Pennsylvania); Wanda K. Nicholson, MD, MPH, MBA (University of North Carolina School of Medicine, Chapel Hill, North Carolina); Douglas K. Owens, MD, MS (Veteran Affairs Palo Alto Health Care System, Palo Alto, and Stanford University, Stanford, California); William R. Phillips, MD, MPH (University of Washington, Seattle, Washington); and Michael P. Pignone, MD, MPH (University of North Carolina, Chapel Hill, North Carolina). Joy Melnikow, MD, MPH, a former USPSTF member, also contributed to the development of this recommendation.
Grade Definitions After July 2012
What the Grades Mean and Suggestions for Practice
The USPSTF updated its definition of and suggestions for practice for the grade C recommendation. This new definition applies to USPSTF recommendations voted on after July 2012. Describing the strength of a recommendation is an important part of communicating its importance to clinicians and other users. Although most of the grade definitions have evolved since the USPSTF first began, none has changed more noticeably than the definition of a C recommendation, which has undergone three major revisions since 1998. Despite these revisions, the essence of the C recommendation has remained consistent: at the population level, the balance of benefits and harms is very close, and the magnitude of net benefit is small. Given this small net benefit, the USPSTF has either not made a recommendation “for or against routinely” providing the service (1998), recommended “against routinely” providing the service (2007), or recommended “selectively” providing the service (2012). Grade C recommendations are particularly sensitive to patient values and circumstances. Determining whether or not the service should be offered or provided to an individual patient will typically require an informed conversation between the clinician and patient.
|Grade||Definition||Suggestions for Practice|
|A||The USPSTF recommends the service. There is high certainty that the net benefit is substantial.||Offer or provide this service.|
|B||The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.||Offer or provide this service.|
|C||The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.||Offer or provide this service for selected patients depending on individual circumstances.|
|D||The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.||Discourage the use of this service.|
|I Statement||The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.||Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.|
Levels of Certainty Regarding Net Benefit
|Level of Certainty*||Description|
|High||The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.|
The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as:
The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:
* The USPSTF defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.
- National Institute on Alcohol Abuse and Alcoholism. Rethinking Drinking: Alcohol and Your Health. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; 2010. Accessed at http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf on 16 April 2013.
- U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office; 2010. Accessed at www.cnpp.usda.gov/publications/dietaryguidelines/2010/policydoc/policydoc.pdf on 16 April 2013.
- Janca A, Ustun TB, van Drimmelen J, Dittmann V, Isaac M. ICD-10 Symptom Checklist for Mental Disorders, Version 1.1. Geneva: World Health Organization; 1994. Accessed at www.who.int/substance_abuse/research_tools/en/english_icd10.pdf on 29 April.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Arlington, VA: American Psychiatric Association; 2000.
- Jonas DE, Garbutt JC, Brown JM, Amick HR, Brownley KA, Council CL, et al. Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse. Comparative Effectiveness Review No. 64. Rockville, MD: Agency for Healthcare Research and Quality; July 2012. Accessed at http://www.ncbi.nlm.nih.gov/books/NBK99199/ on 16 April 2013.
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Source: This article was first published in Annals of Internal Medicine (Ann Intern Med 2013;14 May).
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Internet Citation: Final Recommendation Statement: Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care. U.S. Preventive Services Task Force. May 2013.