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Draft Recommendation Statement


Note: This draft Recommendation Statement is not the final recommendation of the U.S. Preventive Services Task Force. This draft is distributed solely for the purpose of pre-release review. It has not been disseminated otherwise by AHRQ. It does not represent and should not be interpreted to represent an AHRQ determination or policy.

This draft Recommendation Statement is based on an evidence review that was published on September 25, 2012 (available at http://www.uspreventiveservicestaskforce.org/uspstf12/alcmisuse/alcomisart.htm)

The USPSTF makes recommendations about the effectiveness of specific clinical preventive services for patients without related signs or symptoms.

It bases its recommendations on the evidence of both the benefits and harms of the service, and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decisionmaking to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

This draft Recommendation Statement was available for comment from September 24 until October 22, 2012, at 5:00 PM ET. A fact sheet that explains the draft recommendations in plain language is available here.


Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: U.S. Preventive Services Task Force Recommendation Statement
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Summary of Recommendations and Evidence

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen adults, including young adults and pregnant women, for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.

This is a grade B recommendation.

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.

This is an I statement.

Table 1 describes the USPSTF grades, and Table 2 describes the USPSTF classification of levels of certainty about net benefit.

Rationale

Importance

The USPSTF uses the term “alcohol misuse” to define a spectrum of behaviors, including risky or hazardous use (drinking more than recommended daily, weekly, or per occasion amounts), harmful use (a pattern of drinking that is causing physical or mental damage to health), and alcohol abuse and alcohol dependence (both as defined by the “Diagnostic and Statistical Manual of Mental Disorders, 4th ed.” [1]). An estimated 30% of the U.S. population is affected, with most persons engaging 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 States (2, 3).

Detection

The USPSTF found adequate evidence that a number of screening instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity.

Benefits of Detection and Behavioral Counseling Interventions

There is 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 compliance with recommended drinking limits.

Although direct evidence concerning the effectiveness of brief behavioral counseling interventions in pregnant women engaging in alcohol misuse is more limited, studies in the general adult population demonstrate that such interventions reduce alcohol consumption and increase compliance with recommended drinking limits among women of childbearing age.

There is insufficient evidence concerning the effect of screening for alcohol misuse and brief behavioral counseling interventions on outcomes in adolescents.

Harms of Detection and Behavioral Counseling Interventions

There is minimal data available to assess the magnitude of harms of screening for alcohol misuse or the harms of consequent brief behavioral counseling interventions in any population. However, no direct evidence of harms was identified in any study, and given the noninvasive nature of both the screening process and behavioral counseling interventions, the related harms are likely small to none.

USPSTF Assessment

The USPSTF concludes that for adults, including young adults and pregnant women, there is moderate certainty of a moderate net benefit to screening and brief behavioral counseling interventions for alcohol misuse.

For adolescents, the evidence concerning alcohol misuse screening and brief behavioral counseling interventions in primary care settings is insufficient, and the balance of benefits and harms cannot be determined.

Clinical Considerations

Patient Population Under Consideration

The grade B recommendation applies to adults age 18 years and older. The I statement applies to adolescents aged 12 to 17 years. These recommendations do not apply to persons who are actively seeking evaluation or treatment for alcohol use.

Screening Tests

Commonly available screening instruments can reliably detect alcohol misuse. Tests include single-question screening (for example, the National Institute on Alcohol Abuse and Alcoholism [NIAAA] recommends asking “How many times in the past year have you had five [for men] or four [for women and all adults older than age 65 years] or more drinks in a day?”); the Alcohol Use Disorders Identification Test (AUDIT); the Cut-down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire and related tests designed specifically for pregnant women (T-ACE, TWEAK); the Michigan Alcoholism Screening Test (MAST); the Rapid Alcohol Problems Screen (RAPS); and the Alcohol-Related Problems Survey (ARPS), among others. Several of these tests also have abbreviated versions (such as AUDIT-C, SMAST, shARPS).

Of the available screening tools, AUDIT is the most widely studied screening tool for detecting alcohol misuse in primary care settings; both the AUDIT and AUDIT-C tests have good sensitivity and specificity for detecting the full spectrum of alcohol misuse across multiple populations. AUDIT consists of 10 questions and requires approximately 2 to 5 minutes to administer; AUDIT-C consists of three 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. The USPSTF considers these three tools the instruments of choice for alcohol misuse screening in the primary care setting.

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 via 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: 1) very brief single contact (5 minutes or less), 2) brief single contact (6 to 15 minutes), 3) brief multicontact (each contact is 6 to 15 minutes), and 4) extended multicontact (at least one contact is more than 15 minutes). Brief multicontact behavioral counseling appears to have the best evidence of effectiveness; very brief behavioral counseling has limited impact (2, 3).

The USPSTF found that counseling interventions in the primary care setting can improve unhealthy alcohol consumption behaviors in adults engaging in risky or hazardous drinking. Positive outcomes include reductions in weekly alcohol consumption and long-term compliance with recommended drinking limits. Because brief behavioral counseling interventions reduce the proportion of persons who engage in episodes of heavy drinking (which result in high blood alcohol concentration [BAC] levels), indirect evidence supports the effect of screening and brief behavioral counseling interventions on important health outcomes such as probability of experiencing a traumatic injury or death, especially related to motor vehicles.

Although screening detects persons along the entire spectrum of alcohol misuse, trials of behavioral counseling interventions in primary care settings have 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.

Screening Intervals

Evidence is lacking to determine the optimal interval for screening for alcohol misuse in adults.

Suggestions for Practice Regarding I Statement

Potential preventable burden. In 2010, approximately 14% of adolescents in the eighth grade and 41% of those in the twelfth grade reported using alcohol at least once within the last 30 days; 7% and 23%, respectively, reported consuming at least five or more drinks on a single occasion (an episode of heavy use) within the previous 2 weeks (4). Motor vehicle crashes are the leading cause of death for adolescents (5); according to the Substance Abuse and Mental Health Services Administration, in 2009, about 4% of 16-year-olds and 9% of 17-year-olds drove under the influence of alcohol at least once during the previous year (6). Thirty-seven percent of traffic deaths among youth aged 16 to 20 years involve alcohol, and these deaths frequently occur at lower BAC levels compared with other age groups (7).

Costs. 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 due to lost work hours and travel to and from the provider.

Potential harms. Potential harms associated with screening for alcohol misuse include anxiety, stigma or labeling, and interference with the clinician-patient relationship; while evidence is very limited, no direct harms were identified for any population in available studies.

Current practice. 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 misuse (8). Barriers include a perceived lack of time, familiarity with screening tools, training in managing positive results, and available treatment resources (9).

Useful Resources

Several screening instruments for alcohol misuse, as well as resources on primary care–feasible behavioral interventions, are available from the NIAAA at http://www.niaaa.nih.gov/publications/clinical-guides-and-manuals.

The U.S. Task Force on Community Preventive Services has 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 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 and school-based instructional programs to prevent adolescents from riding in motor vehicles with alcohol-impaired drivers; however, the Task Force found insufficient evidence to determine whether such programs reduce alcohol-impaired driving or alcohol-related motor vehicle crashes. More information about policy approaches to alcohol misuse is available at http://www.thecommunityguide.org/alcohol/index.html.

The Cochrane Collaboration has performed two 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 Game (10). Similarly, evidence generally supported small but positive effects from family-based interventions in preventing alcohol misuse in young people (11).

Other Considerations

Research Needs and Gaps

While 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 impact of these interventions on longer-term morbidity, mortality, or quality of life. Most trials of behavioral counseling for screen-detected alcohol misuse focused on risky or hazardous alcohol use; future research could help to explain whether persons engaging in harmful drinking or alcohol abuse might derive 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.

Discussion

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 drinking (12), and the prevalence of current alcohol dependence is about 4% (13). 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 depression (14). Alcohol misuse has also been implicated as a major factor in morbidity and mortality due to trauma, including falls, drownings, fires, motor vehicle crashes, homicide, and suicide (15). Alcohol misuse 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 States (16).

Scope of Review

The USPSTF commissioned a systematic evidence review of randomized, controlled trials and nonrandomized trials with concurrent 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 performed 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 health outcomes (such as alcohol-associated morbidity or mortality), the harms of screening and behavioral counseling interventions, and health care system influences that promote or detract from effective screening and counseling interventions for alcohol misuse.

Accuracy of Screening Tests

There are a multitude of screening instruments available that can detect some or all of the drinking categories included in the spectrum of alcohol misuse. Five fair- to good-quality systematic reviews compared different screening test characteristics in primary care populations (2, 3). Overall, the full AUDIT instrument, the abbreviated AUDIT-C, and single-question screening (asking “How many times in the past year have you had five [for men] or four [for women and all adults older than age 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, they are the preferred screening approaches of the USPSTF.

AUDIT demonstrates an optimal balance of sensitivity and specificity for detecting all forms of alcohol misuse when cut-off points of ≥4 (sensitivity, 84%–85%; specificity, 77%–84%) or ≥5 (sensitivity, 70%–92%; specificity, 73%–94%) are used; the use of higher cut-off points increases specificity to an extent but reduces sensitivity. The sensitivity and specificity of the abbreviated AUDIT-C are best balanced at cut-off points of ≥4 (74%–76% and 80%–83%, respectively) and ≥3 (74%–88% and 64%–83%, respectively). The single-question screening tool has a reported sensitivity of 82% to 87% and specificity of 61% to 79% (2, 3).

Although the CAGE questionnaire has frequently been used in primary care settings as a low-burden screening tool for alcohol disorders, it is important to note that it has comparatively poor sensitivity for identifying risky or hazardous drinking, particularly among older adults and pregnant women (14%–39% and 38%–49%, respectively) (2).

None of the identified systematic reviews provided information about the use of screening tests in adolescents.

Effectiveness of Screening and Behavioral Counseling Interventions

No published studies have 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 the use of brief counseling interventions in adults with screen-detected risky or hazardous drinking positively affects 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 screen-detected alcohol misuse. Most interventions evaluated were either brief or brief multicontact behavioral counseling interventions and were directly provided by primary care physicians. The mean age of participants was generally between 30 and 50 years (2, 3).

Studies show that behavioral counseling interventions reduce binge drinking. Meta-analysis from seven trials demonstrated that behavioral counseling interventions resulted in a 12% absolute increase in the proportion of adult participants with screen-detected risky or hazardous drinking who reported no heavy drinking (or binge) episodes after 1 year compared with the control group (95% confidence interval [CI], 7%–16%). Subgroup analyses suggest that single-contact interventions may be less effective or ineffective compared with multicontact approaches (2, 3). In younger adults (such as college aged), three trials provided evidence that behavioral counseling interventions reduced the frequency of heavy drinking episodes by about 1 day per month (average baseline, 6–7 heavy drinking days per month) at 6 months of followup (17-19). The evidence was insufficient to evaluate whether there are relative differences in the effect for older adults.

Behavioral counseling interventions also reduce the total number of drinks per week consumed by adults with screen-detected risky or hazardous drinking. 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 followup compared with the control group (absolute difference, 3.6 fewer drinks per week [95% CI, 2.4–4.8]) (2, 3). Among younger adults, data from three trials conducted in the United States demonstrated that average consumption decreased from a baseline of about 15 to 13 drinks per week at 6 months of followup (17-19). 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 to about 14 drinks per week at 12 months of followup (20, 21).

Based on a meta-analysis of nine relevant trials, the absolute proportion of adults with screen-detected risky or hazardous drinking who reported not exceeding recommended drinking limits over a period of 12 months increased by 11% (95% CI, 8%–13%) in those receiving behavioral counseling interventions compared with the control group (2, 3). The definition of and rationale behind a given recommended limit of alcohol consumption may vary to some degree across guidelines, making this outcome a somewhat more subjective measure than others evaluated by the USPSTF. A commonly cited standard developed by the NIAAA recommends that healthy adult men age 65 years and younger should have no more than four alcohol drinks per day and no more than 14 drinks per week, healthy adult women and all adults older than age 65 years should have no more than three drinks per day and no more than seven drinks per week, and lower levels of consumption or abstinence should be recommended for adults who take medications that interact with alcohol, have a health condition exacerbated by alcohol, or are pregnant (22). For older adults (age 65 years and older), two studies demonstrated an absolute increase in the proportion of risky or hazardous drinkers who complied with recommended drinking limits after behavioral counseling of 9% (95% CI, 2%–16%) at 1 year of followup (20, 21). There was not enough evidence to assess if 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 receive comprehensive assessment only or assessment plus a 45-minute behavioral counseling intervention. The study found a sustained reduction in the daily consumption of alcohol in both groups (with no statistically significant difference between them); it also found that women who were abstinent from alcohol at baseline in the behavioral intervention group were more likely to remain so than women in the control group (86% vs. 72%; p=0.04) (23). However, as previously described, multiple studies in the general adult population demonstrate that behavioral counseling interventions reduce alcohol consumption and increase compliance with recommended drinking limits among women of childbearing age.

No studies meeting inclusion criteria were identified for the effects of brief behavioral counseling interventions on screen-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 six studies did not find a statistically significant effect of behavioral counseling interventions on all-cause mortality (rate ratio, 0.52 [95% CI, 0.22–1.2]), although findings generally trended favorably for the intervention groups. However, as 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 effect (2, 3). A sizable body of observational evidence does demonstrate a link between increasing alcohol consumption levels and the risk of experiencing a 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 experiencing a motor vehicle crash–related injury found a rapidly rising dose-response relationship between the two variables. With the consumption of 24 g of alcohol (about two standard drinks) within a 6-hour period, the odds ratio of experiencing a motor vehicle crash–related injury 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 to 10, and after 10 drinks, the odds ratio is 52 (24). A review of case-control roadside surveys evaluating the relationship between BAC in drivers involved in motor vehicle crashes compared with drivers not involved in incidents found that the relative probability of experiencing a motor vehicle crash resulting in injury or death increased sharply after attainment of a BAC of about 0.08 g/dL (relative risk across included studies ranged from about 2 to 4 at a BAC of 0.08 g/dL compared with a BAC of 0 g/dL, with sharper increases at higher BAC levels) (25).

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 relevant to persons with alcohol dependence suggests that brief behavioral counseling interventions may be ineffective in this population (2, 3). The effectiveness of behavioral counseling in primary care settings for persons engaging in harmful use or alcohol abuse is uncertain. Although the USPSTF did not formally assess the evidence surrounding interventions for alcohol dependence, a range of treatment options with established efficacy exist, 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 replaced one 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 screen-detected alcohol misuse receiving behavioral counseling, and five studies qualitatively described that cigarette consumption appeared unchanged among adults receiving counseling interventions (2, 3). 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 the use of 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 are applicable to adult women who are pregnant.

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 an increased risk of experiencing motor vehicle crash–related morbidity and mortality, providing indirect support that counseling interventions—which reduce both acute and sustained alcohol intake levels—can play a role in improving some health outcomes in alcohol misuse (24, 25). A large body of observational evidence also links alcohol misuse in pregnant women with an increased risk of subsequent birth defects (26, 27).

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 and pregnant women, 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.

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 Other Groups

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 interventions (28). NIAAA encourages primary care clinicians to incorporate alcohol screening and interventions into their practices, and provides specific tools for implementation of these activities (23).

The American Congress 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, provide assistance for achieving abstinence, or provide effective contraception to women who require help (29).

The American Academy of Pediatrics recommends that clinicians screen all adolescent patients for alcohol use with a formal, validated screening tool, such as the CRAFFT substance abuse screening test, at every health supervision visit and appropriate acute care visits, and respond to screening results with the appropriate brief intervention (30).

Table 1: What the Grades Mean and Suggestions for Practice

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 Note: The following statement is undergoing revision.
Clinicians may provide this service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms there is likely to be only a small benefit from this service.
Offer or provide this service only if other considerations support offering or providing the service in an individual patient.
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.


Table 2: 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.
Moderate The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors such as:
  • The number, size, or quality of individual studies.
  • Inconsistency of findings across individual studies.
  • Limited generalizability of findings to routine primary care practice.
  • Lack of coherence in the chain of evidence.

As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.

Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:
  • The limited number or size of studies.
  • Important flaws in study design or methods.
  • Inconsistency of findings across individual studies.
  • Gaps in the chain of evidence.
  • Findings not generalizable to routine primary care practice.
  • A lack of information on important health outcomes.

More information may allow an estimation of effects on health outcomes.

*The U.S. Preventive Services Task Force 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.

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AHRQ Publication No. 12-05171-EF-2
Current as of October 2012


Internet Citation:

U.S. Preventive Services Task Force. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Draft Recommendation Statement. AHRQ Publication No. 12-05171-EF-2. http://www.uspreventiveservicestaskforce.org/uspstf12/alcmisuser/draftrecalcmisuser.htm



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