Draft Recommendation Statement
Unhealthy Alcohol Use in Adolescents and Adults: Screening and Behavioral Counseling Interventions
This opportunity for public comment expires on July 2, 2018 at 8:00 PM EST
Note: This is a Draft Recommendation Statement. This draft is distributed solely for the purpose of receiving public input. It has not been disseminated otherwise by the USPSTF. The final Recommendation Statement will be developed after careful consideration of the feedback received and will include both the Research Plan and Evidence Review as a basis.
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.
Draft: Recommendation Summary
|Adults age 18 years or older, including pregnant women|
The USPSTF recommends that clinicians in primary care settings screen for unhealthy alcohol use in adults age 18 years or older, including pregnant women, and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use.
|Adolescents ages 12 to 17 years|
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening and brief behavioral counseling interventions for alcohol use in primary care settings in adolescents ages 12 to 17 years.
Send Us Your Comments
In an effort to maintain a high level of transparency in our methods, we open our draft Recommendation Statements to a public comment period before we publish the final version.
The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific clinical preventive services for patients without obvious 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 decision making 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.
The USPSTF uses the term “unhealthy alcohol use” to define a spectrum of behaviors, including exceeding daily or weekly use limits, heavy use episodes, and alcohol use disorder (AUD) (e.g., harmful alcohol use, abuse, or dependence) (Table).1 “Risky” or ”hazardous” alcohol use means drinking more than the recommended daily, weekly, or per-occasion amounts but not meeting criteria for AUD.2 For example, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines “risky use” as exceeding the recommended limits of four drinks per day or 14 drinks per week for healthy adult men age 65 years or younger or three drinks per day or seven drinks per week for healthy adult women age 65 years or younger.2 A standard drink is defined as 12.0 oz of beer, 5.0 oz of wine, or 1.5 oz of liquor.2 The American Society of Addiction Medicine (ASAM) defines “hazardous use” as alcohol use that increases the risk of negative health consequences.3 Any alcohol use is considered unhealthy in pregnant women and adolescents.1 In adolescents, the definition of moderate- or high-risk alcohol use varies by age, based on days of use per year.4 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines the severity of AUD (mild, moderate, or severe) based on the number of criteria met.5 Previous versions of the manual had separate diagnoses for alcohol abuse and alcohol dependence but DSM-5 no longer separates these diagnoses.1
Excessive alcohol use is one of the most common causes of premature mortality in the United States. From 2006 to 2010, approximately 88,000 alcohol-attributable deaths occurred annually in the United States, due to both acute conditions (e.g., injuries from motor vehicle collisions) and chronic conditions (e.g., alcoholic liver disease).1, 6 It is also one of the major preventable causes of birth defects and developmental disabilities when used in pregnancy.7
The USPSTF found adequate evidence that numerous screening instruments can detect unhealthy alcohol use with acceptable sensitivity and specificity in primary care settings.
Benefits of Early Detection and Behavioral Counseling Interventions
The USPSTF found no studies that directly evaluated whether screening for unhealthy alcohol use in adolescents and adults, including pregnant women, in primary care settings leads to reduced unhealthy alcohol use; improved risky behaviors; or improved health, social, or legal outcomes.
The USPSTF found adequate evidence that brief behavioral counseling interventions in adults who screen positive are associated with reduced unhealthy alcohol use. There were reductions in both the odds of exceeding recommended drinking limits and heavy use episodes at 6- to 12-months’ follow-up. In pregnant women, brief counseling interventions increased the likelihood that women remained abstinent from alcohol use during pregnancy. The magnitude of these benefits is moderate. Epidemiologic literature links reductions in alcohol use with reductions in risk for morbidity and mortality and provides indirect support that reduced alcohol consumption may help improve some health outcomes.1, 8
The USPSTF found inadequate evidence that brief behavioral counseling interventions in adolescents were associated with reduced alcohol use.
Harms of Screening and Behavioral Counseling Interventions
The USPSTF found adequate evidence to bound the harms of screening and brief behavioral counseling interventions for unhealthy alcohol use in adults, including pregnant women, as small to none, based on the likely minimal harms of the screening instruments, the noninvasive nature of the interventions, and the absence of reported harms in the evidence on behavioral interventions.
The USPSTF found inadequate evidence on the harms of screening and brief behavioral counseling interventions for alcohol use in adolescents.
The USPSTF concludes with moderate certainty that there is a moderate net benefit to screening and brief behavioral counseling interventions for unhealthy alcohol use in the primary care setting for adults age 18 years or older, including pregnant women.
The USPSTF concludes that the evidence is insufficient to determine the benefits and harms of screening for unhealthy alcohol use in adolescents ages 12 to 17 years in the primary care setting.
Draft: Clinical Considerations
Patient Population Under Consideration
The B recommendation applies to adults age 18 years or older and includes pregnant women. The I statement applies to adolescents ages 12 to 17 years. These recommendations do not apply to persons who have a current diagnosis of or who are seeking evaluation or treatment for alcohol abuse or dependence.
Of the available screening tools, the USPSTF determined that one- to three-item screening instruments have the best accuracy for assessing unhealthy alcohol use in adults age 18 years or older.1 These instruments include the abbreviated Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and the NIAAA-recommended Single Alcohol Screening Question (SASQ). The Cut down, Annoyed, Guilty, Eye-opener (CAGE) tool is well known but only detects alcohol dependence rather than the full spectrum of unhealthy alcohol use.1
The abbreviated AUDIT-C has good sensitivity and specificity for detecting the full spectrum of unhealthy alcohol use across multiple populations.1 AUDIT-C has three questions that ask about frequency of alcohol use, typical amount of alcohol use, and occasions of heavy use, and takes 1 to 2 minutes to administer. SASQ also has adequate sensitivity and specificity across the unhealthy alcohol use spectrum and requires less than 1 minute to administer, 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?”1
When patients screen positive on a brief screening instrument, clinicians should follow up with a more in-depth risk assessment to confirm unhealthy alcohol use and determine the next steps of care. Evidence supports the use of brief instruments, with higher sensitivity and lower specificity, as initial screening followed by a longer instrument with greater specificity (e.g., AUDIT). AUDIT has a total of 10 questions; three questions covering frequency of alcohol use, typical amount of alcohol use, and occasions of heavy use, and seven questions on the signs of alcohol dependence and common problems associated with alcohol use (e.g., being unable to stop once you start drinking). It requires approximately 2 to 5 minutes to administer.1
Screening instruments have been specifically developed for various populations. Screening tools for pregnant women include Tolerance, Worried, Eye-opener, Amnesia, Kut down (TWEAK); Tolerance, Annoyed, Cut down, Eye-opener (T-ACE); Parents, Partner, Past, Present Pregnancy (4P’s Plus); and the Normal drinker, Eye-opener, Tolerance (NET). The NIAAA and American Academy of Pediatrics recommend the Car, Relax, Alone, Forget, Family, Friends, Trouble (CRAFFT) screening instrument for identifying risky substance use in adolescents. The NIAAA also recommends asking patients about their own alcohol use as well as their friends’ alcohol use. The Comorbidity Alcohol Risk Evaluation Tool (CARET) is a screening instrument used in older adults.1 The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), developed by the World Health Organization (WHO), screens for substance and alcohol use in adults.1, 9
Behavioral Counseling Interventions
Behavioral counseling interventions for unhealthy alcohol use vary in their specific components, administration, length, and number of interactions. Thirty percent of the interventions reviewed by the USPSTF were Web-based. Nearly all of the interventions consisted of four or fewer sessions; the median number of sessions was one (range, 0 to 21). The median length of time of contact was 30 minutes (range, 1 to 600 minutes). Most of the interventions had a total contact time of 2 hours or less.1 Primary care settings often used the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach. Interventions targeting adults other than college students (including pregnant and postpartum women) were more likely to take place in primary care settings, have multiple sessions, and involve a primary care team.1 Most interventions involved participants receiving general feedback (e.g., how their drinking fits with recommended limits, how to reduce alcohol use). The most commonly reported intervention component was use of personalized normative feedback sessions, in which participants were shown how their alcohol use compares to others; more than half of the included trials and almost all trials in young adults used this technique.1 Most trials in young adults involved one or two in-person or Web-based personalized normative feedback sessions in university settings. Personalized normative feedback was often combined with motivational interviewing or more extensive cognitive behavioral counseling. Other cognitive behavioral strategies, such as drinking diaries, action plans, alcohol use “prescriptions,” stress management, or problem solving were also frequently used. About one-third of the intervention trials in general and older adult populations involved a primary care team.1
The USPSTF found no evidence to suggest that patients of different race/ethnicity or lower socioeconomic status have a lower likelihood of benefit from interventions. Effects of interventions were similar in men and women.1
The USPSTF did not find adequate evidence to recommend an optimal screening interval for unhealthy alcohol use in adults.
Suggestions for Practice Regarding the I Statement
Potential Preventable Burden
In 2016, the National Survey on Drug Use and Health reported that an estimated 9.2% of adolescents ages 12 to 17 years drink alcohol and 4.9% had an episode of binge drinking in the last 30 days.10 Each year, excessive drinking in underage youth leads to more than 4,300 deaths.11 Driving while under the influence of alcohol is particularly hazardous among adolescents. The 2015 Youth Risk Behavior Survey found that about 8% of high school students who drove a car in the last 30 days reported driving after drinking alcohol, and 20% reported riding with a driver who had been drinking.12 In 2010, one in five teen drivers involved in a fatal motor vehicle collision had some alcohol in their system, and most had blood alcohol levels higher than the legal limit for adults.13
Possible harms of screening for unhealthy alcohol use include stigma, anxiety, labeling, discrimination, privacy concerns, and interference with the patient-provider relationship. The USPSTF did not find any evidence that specifically examined the harms of screening for alcohol use in adolescents.
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.14 Primary care clinicians screened for unhealthy alcohol use in more than half of their adolescent patients; screening was more likely if adolescents were older (ages 15 to 17 years). However, the quality of screening practices, tools used, and interventions provided varied widely.15 Current data on rates of screening are lacking. Reported barriers to screening include time constraints, lack of knowledge about best practices, and lack of availability of services should an adolescent patient screen positive.1, 14, 15
The AUDIT and AUDIT-C, which screen for unhealthy alcohol use in adults age 18 years or older, including pregnant women, are available from the Substance Abuse and Mental Health Service Administration.16 More information about SASQ and counseling for unhealthy alcohol use is available from NIAAA.17 Clinician guides are available from WHO18 and the American Academy of Family Physicians.19 An implementation guide for primary care practices is available from the Centers for Disease Control and Prevention.20
The Community Preventive Services Task Force recommends electronic screening and brief interventions to reduce excessive alcohol consumption in adults. It found limited information on the effectiveness of electronic screening and brief interventions in adolescents.21 The Community Preventive Services Task Force has also evaluated public health interventions (i.e., interventions occurring outside of the clinical practice setting) to prevent excessive alcohol consumption.22
Draft: Other Considerations
Research Needs and Gaps
The USPSTF has identified several research gaps. Although difficult, conducting a trial with an unscreened comparison group to understand the population-level effects of screening in primary care settings would be valuable. More direct evidence is needed on the harms associated with screening and behavioral interventions. USAUDIT and USAUDIT-C are recent U.S. adaptations of AUDIT and AUDIT-C. The USPSTF found no eligible studies that evaluated the USAUDIT and USAUDIT-C. Test performance studies of USAUDIT and USAUDIT-C are needed to confirm their accuracy in identifying unhealthy alcohol use. More evidence on important clinical outcomes is needed, such as longer-term morbidity, mortality, health care utilization, and social and legal outcomes. Trials designed a priori to report subgroup effects in diverse populations (e.g., by age, sex, race/ethnicity, baseline severity) would be useful. 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. In addition, studies in adolescents are often conducted in school settings, which may not translate to primary care settings. More studies of adolescents in primary care settings are needed.
Burden of Disease
High-risk drinking increased by almost 30% between 2001–2002 and 2012–2013.25 In 2016, approximately 26.2% of adults age 18 years or older reporting heavy use (binge drinking) episodes and 6.6% reporting heavy drinking within the previous month;26 an estimated 7.8% of men and 4.2% of women met the criteria for AUD.10 Excessive alcohol use is one of the most common causes of premature mortality in the United States.6 One out of 10 deaths among adults ages 20 to 64 years can be attributed to excessive alcohol use.6 In the United States, from 2006 to 2010, approximately 88,000 deaths each year were attributed to alcohol use, with an estimated 2.5 million years of potential life lost.6 Of these 88,000 deaths, 44% were due to chronic conditions (e.g., alcoholic liver disease) and 56% were due to acute conditions (e.g., injuries from motor vehicle collisions).6 Excessive alcohol use also contributed to 3.2% to 3.7% of cancer deaths, including breast, gastrointestinal, oral cavity, and neck cancer.26 Among adolescents ages 12 to 17 years, 9.2% reported being current alcohol users and 4.9% reported heavy use episodes in the previous month. Approximately 488,000 adolescents have AUD (2.4% and 1.5% of female and male adolescents, respectively).10 In 2005, unhealthy alcohol use in college students ages 18 to 24 years contributed to the death of 1,825 students through unintentional injuries (e.g., motor vehicle collisions),27, 28 and about one in four students report that alcohol use contributes to missing or falling behind in classes, low grades, and poor performance on examinations and papers.27, 29 In 2010, excessive alcohol use cost the United States an estimated $249 billion in loss in workplace productivity, health care expenses, criminal justice expenses, and motor vehicle collisions.30 Alcohol use during pregnancy is a major preventable cause of birth defects and developmental disabilities, including fetal alcohol spectrum disorders, and affects development of the fetal brain, endocrine system, gastrointestinal tract, heart, kidney, and liver.7 The 2011–2013 Behavioral Risk Factor Surveillance System survey show that 1 in 10 pregnant women ages 18 to 44 years reported consuming alcohol in the previous month, and 3.1% participated in binge drinking.31
Scope of Review
The USPSTF commissioned a systematic evidence review to update its 2013 recommendation on screening for unhealthy alcohol use in primary care. In the previous recommendation, the USPSTF used the term “alcohol misuse” to define a wide range of drinking behaviors (e.g., risky or hazardous alcohol use, harmful alcohol use, and alcohol abuse or dependence).32 In accordance with ASAM, the current recommendation uses the term “unhealthy use” rather than “misuse.” ASAM defines “unhealthy use” as any use of alcohol that increases the risk of health consequences or has already led to health consequences, including an AUD diagnosis.1, 4 The evidence review examined the effectiveness of screening to reduce unhealthy alcohol use, morbidity, mortality, or risky behaviors and improve health, social, or legal outcomes; the accuracy of various screening approaches; the effectiveness of counseling interventions in reducing unhealthy alcohol use, morbidity, mortality, or risky behaviors and improve health, social, or legal outcomes; and the harms of screening and behavioral counseling interventions. The review did not include treatment with medications because medications are used to treat severe AUD and are not routinely used in screen-detected persons. Interventions to prevent alcohol use in adolescents was determined to be out of scope for this review.1
Accuracy of Screening Tests
Forty-five studies (n=277,881) addressed the accuracy of screening tools; 10 studies in adolescents, five studies in young adults, 27 studies in general adult populations, one study in older adults, and two studies in pregnant or postpartum women. Twenty-eight studies were of fair quality and 17 were of good quality. Most of the studies took place in the United States (62%), and 51% of the studies recruited patients from primary care settings.1
Studies evaluated AUDIT, AUDIT-C, ASSIST, and a variety of one- or two-item screening tests for detecting the full spectrum of unhealthy alcohol use. Screening instruments addressed a variety of elements, such as the quantity of drinks, drinking frequency, or the typical total number of drinks over a specific time period (quantity x frequency), and a variety of response categories and cutoffs.1
Reference standards were structured diagnostic interviews (e.g., Composite International Diagnostic Interview [CIDI], Alcohol Use Disorder and Associated Disabilities Interview Schedule [AUDADIS], or Mini International Neuropsychiatric Interview Plus [MINI-Plus]). Some studies used a diagnostic interview in combination with other instruments (e.g., in combination with ASSIST, to identify the full spectrum of unhealthy alcohol use) or a timeline follow-back interview.1
For adults, AUDIT, AUDIT-C, and one- or two-item screening tests had acceptable sensitivity and specificity to detect the full spectrum of unhealthy alcohol use. Studies of SASQ reported sensitivity of 0.73 to 0.88 (95% CI range, 0.65 to 0.89) and specificity of 0.74 to 1.00 (95% CI range, 0.69 to 1.00) for detecting unhealthy alcohol use (4 studies; n=44,461). Other one- or two-item screening tests generally showed sensitivity of 0.70 or greater. The standard of six or more drinks per occasion tended to have decreased sensitivity compared with the standard of five (men)/four (women) or more drinks, often with nonoverlapping confidence intervals. Other adult populations (young adults, older adults, and pregnant women) had similar results.1
Seven studies (n=8,852) evaluating AUDIT for the detection of unhealthy alcohol use in general adult populations, using the recommended cutoff of higher than 8, reported a wide range of sensitivity (0.38 to 0.73 [95% CI range, 0.33 to 0.84]) but high specificity (0.89 to 0.97 [95% CI range, 0.84 to 0.98]). In many studies, sensitivity improved at lower cutoffs. Three studies (n=2,782) conducted in U.S. primary care settings showed better accuracy (sensitivity, 0.64 to 0.86 [95% CI range, 0.57 to 0.91] and specificity, 0.74 to 0.94 [95% CI range, 0.68 to 0.95] at cutoffs of 3, 4, or 5).1
Sensitivity of AUDIT-C for detecting unhealthy alcohol use in adults was similar to that of one- or two-item screening instruments. In most studies, the range of sensitivity was 0.73 to 0.97 for females (95% CI range, 0.62 to 0.99; 5 studies; n=2,714) and 0.82 to 1.00 for males (95% CI range, 0.75 to 1.00; 4 studies; n=1,038) at the standard cutoffs of 3 or higher for females and 4 or higher for males, but the range of specificity was much wider (0.28 to 0.91 [95% CI range, 0.21 to 0.93] and 0.34 to 0.89 [95% CI range, 0.25 to 0.92] for females and males, respectively). Evidence on the use of AUDIT-C in younger adults, older adults, and pregnant women was lacking.1
No studies among pregnant women reported on the test accuracy of any screening test for alcohol use or the full spectrum of unhealthy alcohol use (e.g., AUDIT-C, AUDIT, ASSIST, TWEAK, or T-ACE).1
A study in American Indian women reported the test accuracy of one- or two item screening instruments (quantity x frequency) to screen for any alcohol use during pregnancy. At the optimal cutoff, sensitivity was 0.77 (95% CI, 0.68 to 0.83) and specificity was 0.93 (95% CI, 0.86 to 0.96).33
Although multiple studies among adolescents demonstrated good accuracy of one- or two-item screening instruments and AUDIT for detecting AUD, none reported on test accuracy for screening for the full spectrum of unhealthy alcohol use.1 Only one study evaluated the accuracy of detecting unhealthy alcohol use in adolescents. A study (n=225) in a German high school reported on the test accuracy of AUDIT-C for detecting the full spectrum of unhealthy alcohol use (males and females combined), with a sensitivity of 0.73 (95% CI, 0.60 to 0.83) and a specificity of 0.81 (95% CI, 0.74 to 0.86) at the optimal cutoff of 5 or higher.34 Evidence to determine whether brief (1- to 3-item) screening instruments or AUDIT can detect alcohol use in adolescents was lacking.1
Effectiveness of Screening and Behavioral Counseling Interventions
No trials examined the direct effects of screening for unhealthy alcohol use on alcohol use or health, social, or legal outcomes.
Alcohol Use and Other Risky Behaviors
Ten good-quality trials and 58 fair-quality trials (n=36,528) reported alcohol use and other risky behaviors. The majority of trials (60%) were conducted in the United States. Intervention settings were predominantly in primary care clinics (62%).1 Two trials were in adolescents, 22 focused on college-age or young adults, 29 addressed general adult populations, four looked at older adults, and 11 focused on pregnant or postpartum women.1 Trials were generally limited to study participants who reported a prespecified level of alcohol use on a screening instrument such as AUDIT. Outcomes were generally reported at 6- to 12-months’ followup or during the late pregnancy/early postpartum period for abstinence during pregnancy. Trials demonstrated high heterogeneity; effect size was not clearly associated with any intervention characteristics. Data on effectiveness in important subpopulations were very limited.1 The most commonly reported subpopulation analysis (by sex) did not show differences in the effectiveness of the interventions.1 The most commonly reported alcohol use outcome was number of drinks per week. Among 37 adult trials (n=15,974), adults in intervention groups reduced the number of drinks per week more than adults in control groups (weighted mean difference between groups in change from baseline, -1.59 [95% CI, -2.15 to -1.03; I2=63%). The proportion exceeding recommended drinking limits was reduced (odds ratio [OR], 0.60 [95% CI, 0.53 to 0.67]), as well as the proportion reporting a heavy use episode (OR, 0.67 [95% CI, 0.58 to 0.77]). Analyses limited to trials conducted in U.S. primary care settings suggest that effects in the most applicable trials were comparable or larger than the overall effect (weighted mean difference, -2.82 [95% CI, -3.87 to -1.76]).1
Interventions among adults resulted in an absolute increase of 14% more participants drinking within recommended limits, meaning 7 adults would need to be treated to get 1 adult drinking within recommended limits (number needed to treat, 7.2 [95% CI, 6.2 to 11.5]).1
Interventions increased the proportion of pregnant women reporting abstinence (OR, 2.26 [95% CI, 1.43 to 3.56]). Based on these results, interventions doubled the odds that women remain abstinent from alcohol during pregnancy (number needed to treat, 6.0 [95% CI, 4.3 to 12.5]).1 Evidence on the effects of interventions to reduce unhealthy alcohol use in adolescents was limited to two trials; both found mixed results for reduced alcohol use.1
Benefits continued 24 months or beyond in four of seven trials with longer-term outcomes. Very limited data suggest that benefits from alcohol use interventions can be maintained over 2 to 4 years, including the number of drinks per week and some health outcomes.1 However, several trials in younger adults found that beneficial effects appeared at 6 months but were no longer statistically significant at 12 months, suggesting that beneficial effects may deteriorate more quickly in younger adults.1
Few changes in other behavioral outcomes (e.g., drug use, sex after alcohol use, and seeking help for unhealthy alcohol use) were observed and were rarely reported.1
Health, Social, and Legal Outcomes
Forty-one good- and fair-quality trials (n=20,324) reported health, social, and legal outcomes; however, no particular outcomes were commonly reported. In addition, reported outcomes were generally not statistically significant and inconsistently favored the intervention group.1 In adults, eight trials reported a statistically nonsignificant reduction in all-cause mortality (OR, 0.64 [95% CI, 0.34 to 1.19]).1 One good-quality study showed reductions in emergency department visits and controlled substance or liquor violations at 4-year’s followup.35 Trials of young adults demonstrated a small reduction in alcohol-related consequences (standardized mean difference, -0.06 [95% CI, -0.11 to -0.01]).1
Potential Harms of Screening and Behavioral Counseling Interventions
Potential harms of screening include stigma, labeling, discrimination, privacy concerns, and interference with the patient-provider relationship.1 In addition, there may be legal concerns for pregnant women in some states.36 No studies evaluated the harms of screening for unhealthy alcohol use.
Possible harms of behavioral counseling interventions may include an unexpected paradoxical increase in alcohol consumption. One good-quality and five fair-quality trials (n=3,650) reported on harms. There was very limited evidence on intervention harms.1 Interventions reviewed and discussed above generally reported benefits, including reductions in alcohol consumption. Therefore, paradoxical and theoretical increases in alcohol use with interventions is unlikely.1
Estimate of Magnitude of Net Benefit
Adequate evidence supports a moderate beneficial effect of screening for unhealthy alcohol use followed by brief behavioral counseling interventions in adults. Screening and behavioral counseling interventions in the primary care setting can reduce unhealthy drinking behaviors in adults, including heavy episodic drinking, high daily or weekly levels of alcohol consumption, and exceeding recommended drinking limits. Although the USPSTF found limited specific evidence for pregnant women, it determined that available studies of behavioral counseling interventions for unhealthy alcohol use in pregnant adult women supported increased likelihood of alcohol abstinence during pregnancy with intervention.
Available studies have not focused on the effects of screening and behavioral counseling interventions on longer-term health outcomes, such as alcohol-related disease or death. However, adequate epidemiologic evidence links reduced levels of alcohol consumption with a reduced risk for morbidity and mortality, providing indirect support that behavioral counseling interventions that reduce acute and sustained alcohol intake levels can help improve some health outcomes of unhealthy alcohol use.8 A large body of observational evidence also links alcohol use in pregnant women with an increased risk for subsequent birth defects, such as fetal alcohol spectrum disorder.37, 38
Given the noninvasive nature of screening and behavioral counseling interventions for unhealthy alcohol use, the USPSTF determined the magnitude of harms to be small to none in adults and pregnant women. Therefore, the USPSTF concludes with moderate certainty that the net benefit of screening and brief behavioral counseling interventions for unhealthy alcohol use in adults, including pregnant women, is moderate.
Evidence in adolescents is limited. As such, the USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of screening and brief behavioral counseling interventions for unhealthy alcohol use in adolescents.
Draft: Update of Previous USPSTF Recommendation
This recommendation replaces the 2013 USPSTF recommendation statement on screening and behavioral counseling interventions for alcohol misuse. The term “alcohol misuse,” used in the 2013 recommendation, has been replaced by the term “unhealthy alcohol use.”
Draft: Recommendations of Others
The U.S. Department of Veterans Affairs, the U.S. Surgeon General, NIAAA, the Centers for Disease Control and Prevention, and ASAM recommend that adult patients should be routinely screened for unhealthy alcohol use and provided with appropriate interventions, if needed.4, 21, 39-41 The American Academy of Pediatrics recommends that clinicians screen all adolescent patients for alcohol use with a formal, validated screening tool (such as CRAFFT) at every health supervision visit and appropriate acute care visits, and respond to screening results with the appropriate brief intervention and referral if indicated. Pediatricians should become familiar with adolescent SBIRT approaches and their potential for incorporation into universal screening and comprehensive care of adolescents in the medical home.42 The American College of Obstetricians and Gynecologists and WHO recommend that all women should be screened for unhealthy alcohol use before pregnancy and in their first trimester with a validated tool, and that providers should offer a brief intervention to all pregnant women using alcohol.43, 44
Send Us Your Comments
In an effort to maintain a high level of transparency in our methods, we open our draft Recommendation Statements to a public comment period before we publish the final version.
1. O’Connor EA, Perdue LA, Senger CA, et al. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Unhealthy Alcohol Use in Adolescents and Adults: Updated Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 171. AHRQ Publication No. 18-05242-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2018.
2. National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician's Guide. Rockville, MD: National Institutes of Health; 2005.
3. American Society of Addiction Medicine. Terminology related to the spectrum of unhealthy substance use. 2013. http://www.asam.org/docs/default-source/public-policy-statements/1-terminology-spectrum-sud-7-13.pdf?sfvrsn=2. Accessed May 28, 2018.
4. National Institute on Alcohol Abuse and Alcoholism. Alcohol Screening and Brief Intervention for Youth: A Practitioner's Guide. Rockville, MD: National Institutes of Health; 2011.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Association; 2013.
6. Stahre M, Roeber J, Kanny D, Brewer RD, Zhang X. Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Prev Chronic Dis. 2014;11:E109.
7. Ismail S, Buckley S, Budacki R, et al. Screening, diagnosing and prevention of fetal alcohol syndrome: is this syndrome treatable? Dev Neurosci. 2010;32(2):91-100.
8. Roerecke M, Gual A, Rehm J. Reduction of alcohol consumption and subsequent mortality in alcohol use disorders: systematic review and meta-analyses. J Clin Psychiatry. 2013;74(12):e1181-9.
9. Humeniuk R, Henry-Edwards S, Ali R, Poznyak V, Monteiro M. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): Manual for Use in Primary Care. Geneva, Switzerland: World Health Organization; 2010.
10. Center for Behavioral Health Statistics and Quality. Results From the 2016 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2017.
11. Centers for Disease Control and Prevention. Fact sheets—underage drinking. https://www.cdc.gov/alcohol/fact-sheets/underage-drinking.htm. Accessed May 28, 2018.
12. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance—United States, 2015. MMWR Surveill Summ. 2016;65(6):1-174.
13. Centers for Disease Control and Prevention. Teen drinking and driving: a dangerous mix. https://www.cdc.gov/vitalsigns/teendrinkinganddriving/index.html. Accessed May 28, 2018.
14. Van Hook S, Harris SK, Brooks T, et al; New England Partnership for Substance Abuse Research. The “Six T’s”: barriers to screening teens for substance abuse in primary care. J Adolesc Health. 2007;40(5):456-61.
15.Millstein S, Marcell A. Screening and counseling for adolescent alcohol use among primary care physicians in the United States. Pediatrics. 2003;111(1):114-22.
16. SAMHSA-HRSA Center for Integrated Health Solutions. Screening tools. https://www.integration.samhsa.gov/clinical-practice/screening-tools. Accessed May 28, 2018.
17. National Institute on Alcohol Abuse and Alcoholism. Professional education materials. https://www.niaaa.nih.gov/publications/clinical-guides-and-manuals. Accessed May 28, 2018.
18. Humeniuk R, Henry-Edwards S, Ali R, Poznyak V, Monteiro M. The ASSIST-Linked Brief Intervention for Hazardous and Harmful Substance Use: A Manual for Use in Primary Care. Geneva, Switzerland: World Health Organization; 2010.
19. American Academy of Family Physicians. Addressing Alcohol Use Practice Manual: An Alcohol Screening and Brief Intervention Program. https://www.aafp.org/dam/AAFP/documents/patient_care/alcohol/alcohol-manual.pdf. Accessed May 28, 2018.
20. Centers for Disease Control and Prevention. Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices. 2014. https://www.cdc.gov/ncbddd/fasd/documents/alcoholsbiimplementationguide.pdf. Accessed May 28, 2018.
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Draft: Table. Terms and Definitions of Unhealthy Alcohol Use
|Low-risk use/ lower-risk use||ASAM||Consumption of alcohol below the amount identified as hazardous and in situations not defined as hazardous|
|Risky/at-risk use||NIAAA||Consumption of alcohol above the recommended daily, weekly, or per-occasion amounts but not meeting criteria for alcohol use disorder
For women: No more than 3 drinks/day and no more than 7 drinks/week
For men: No more than 4 drinks/day and no more than 14 drinks/week
Should avoid alcohol completely: Adolescents, women who are pregnant or trying to get pregnant, and adults who plan to drive a vehicle or operate machinery, are taking medication that interacts with alcohol, or have a medical condition that can be aggravated by alcohol
For adolescents: NIAAA defines moderate- and high-risk use based on days of alcohol use in the past year, by age group:
|Unhealthy use||ASAM||Any alcohol use that increases the risk or likelihood of health consequences (hazardous use [see below]) or has already led to health consequences (harmful use [see below])|
|Hazardous use||WHO||A pattern of substance use that increases the risk of harmful consequences; in contrast to harmful use, hazardous use refers to patterns of use that are of public health significance, despite the absence of a current alcohol use disorder in the individual user|
|ASAM||Alcohol use that increases the risk or likelihood of health consequences; does not include alcohol use that has already led to health consequences|
|Harmful use||WHO||A pattern of drinking that is already causing damage to health; the damage may be either physical (e.g., liver damage from chronic drinking) or mental (e.g., depressive episodes secondary to drinking)
The description for ICD-10 code F10.1, also labeled “Alcohol Abuse” in the 2018 ICD-10-CM codebook
|ASAM||Consumption of alcohol that results in health consequences in the absence of addiction|
|Alcohol use disorder||DSM-5||A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:
Mild: 2–3 symptoms
Moderate: 4–5 symptoms
Severe: ≥6 symptoms
|Binge drinking/ heavy drinking episodes*||NIAAA||A pattern of drinking that brings blood alcohol concentration levels to 0.08 g/dL, which typically occurs after 4 drinks for women and 5 drinks for men—in about 2 hours|
|SAMHSA||Drinking ≥5 alcoholic drinks on the same occasion on at least 1 day in the past 30 days|
|Heavy drinking||SAMHSA||Drinking ≥5 drinks on the same occasion on each of ≥5 days in the past 30 days|
|≥3 of the following at some time during the previous year:
*According to ASAM, the preferred term is “heavy drinking episode.”
Abbreviations: ASAM=American Society of Addiction Medicine; DSM-5=Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; NIAAA=National Institute on Alcohol Abuse and Alcoholism; SAMHSA=Substance Abuse and Mental Health Services Administration; WHO=World Health Organization; ICD-10-CM=International Classification of Diseases-10-Classification of Mental and Behavioural Disorders.
Internet Citation: Draft Recommendation Statement: Unhealthy Alcohol Use in Adolescents and Adults: Screening and Behavioral Counseling Interventions. U.S. Preventive Services Task Force. June 2018.