Unhealthy Alcohol Use in Adolescents and Adults: Screening and Behavioral Counseling Interventions

Unhealthy alcohol use (UAU) is a leading cause of preventable death in US adults.^1,2 Generally alcohol-related deaths are due to the health effects of chronic excessive use (e.g. heart disease, cancer and liver disease).^1,2 However, alcohol-related injuries are a significant cause of loss of life especially among young adults.³ Alcohol consumption during pregnancy can result in fetal alcohol spectrum disorders and additional adverse birth outcomes.⁴ Alcohol initiation at younger ages when the brain is rapidly developing and changing may contribute to an increased risk of unhealthy alcohol use.⁵

The USPSTF concludes with moderate certainty that screening for UAU in adults, including those who are pregnant, and providing brief counseling interventions to adults who screen positive for UAU behaviors has a moderate net benefit. Evidence is lacking on screening for UAU in adolescents and the balance of benefits and harms cannot be determined.

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.⁶

Patient Population under Consideration

This recommendation applies to adults 18 years and older, including those who are pregnant. The recommendation does not apply to adults or adolescents previously diagnosed with UAU or those seeking evaluation or treatment for UAU.

Definitions

UAU refers to a spectrum of behavior from risky drinking to alcohol use disorder (AUD). No level of alcohol consumption is known to be safe. “Risky” or” hazardous” alcohol use refers to consumption above recommended daily, weekly, or per-occasion amounts, resulting in increased risk for health but not meeting criteria for AUD.¹ Alcohol Use Disorder refers to “a maladaptive pattern of alcohol use leading to clinically significant impairment or distress”, as manifested by two (or more) criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.^1,7 According to the Centers for Disease Control and Prevention, binge drinking can be defined as 5 or more drinks for men or 4 or more drinks for women during an occasion.⁸

The review focused on screening for UAU and reducing consumption below levels defined by US guidelines as hazardous.¹ According to the US Department of Agriculture and the US Department of Health and Human Services, drinking in moderation is defined as no more than 2 drinks in a day for men and no more than 1 drink in a day for women; pregnant women should not consume alcohol.⁹

Assessment of Risk

Alcohol consumption is common in the US across age, place, race, ethnicity, and sex. All adults including pregnant women are at risk for unhealthy alcohol use and should be screened for UAU.

Screening Tests

Given time constraints in the primary care setting, brief or self adminstered screening instruments that can identify the full spectrum of alcohol use are preferable.¹ When patients screen positive on brief screening instruments, clinicians should follow-up with more in-depth assessment to confirm UAU and determine next steps of care.¹

In 2018, the USPSTF identified several brief instruments that can detect unhealthy alcohol use in the primary care setting including the Single Item Alcohol Screening Questionnaire (SASQ), the AUDIT-Consumption (AUDIT-C), and the Alcohol Use Disorders Identification Test (AUDIT) in adults.¹ The SASQ instrument asks, “How many times in the past year have you had 5 [for men]/4 [for women] or more drinks in a day?”, one or more occasions in the previous year constitutes a positive screen.¹ The AUDIT-C includes 3 questions about frequency of alcohol use, typical amount of alcohol use, and occasions of heavy use.¹ The AUDIT includes 10 questions, 3 AUDIT-C plus 7 questions concerning signs of alcohol dependence and common problems associated with alcohol use.¹ The current review focused on USAUDIT and USAUDIT-C, which align with typical drink sizes in the US (14 grams vs 10 grams internationally) and may be more relevant to a US primary care setting but were not previously reviewed by the USPSTF.¹

Screening instruments have been developed specifically for adolescent populations such as the National Institute on Drug and Alcohol Abuse’s Brief Screener for Tobacco, Alcohol and other Drugs (BSTAD).¹ This instrument asks about the adolescent’s alcohol use as well as their friend’s alcohol use.¹ BSTAD and another screening instrument, the Screening to Brief Intervention (S2BI) are designed to generate a risk level for alcohol use and on the use of additional substances such as cannabis.^1,10 Other screening tools such as the Car, Relax, Alone, Forget, Family, Friends, Trouble (CRAFFT) assesses riding in or driving a car while intoxicated, use of alcohol or drugs to relax, use when alone, forgetting what you’ve done while intoxicated, having friends or family suggest you cut down, and getting into trouble while using alcohol or drugs.¹

Behavioral Counseling Interventions

For individuals engaged in unhealthy drinking behaviors, counseling interventions can increase alcohol use awareness and motivation to make behavioral changes. People with AUD may need referrals to more extensive treatment possibly including pharmacotherapy.¹ The current review focused on behavioral counseling which are first-line interventions and commonly used after individuals screen positive for unhealthy alcohol use.

Reviewed behavioral counseling interventions for unhealthy alcohol use varied.¹ Overall, most interventions involved human contact by phone or in-person. Digital delivery was more common among young adults.¹ Most interventions were brief, 15 minutes or less and completed in a single session.¹ Interventions often used the Screening, Brief Intervention, and the Referral to Treatment (SBIRT) approach and included components of the Ask, Advise, Assess, Assist, Arrange (5 A’s) mnemonic.¹ Once clinicians identify unhealthy alcohol use, they can provide feedback to the patient on their alcohol use; advise the patient to reduce their alcohol use; have a discussion with the patient to understand their readiness to change; develop goals and an action plan; and arrange for followup.¹

Many factors can impact access to interventions to reduce UAU. According to the 2023 National Survey on Drug Use and Health survey common barriers to receiving interventions include believing one could handle substance use on one’s own; not being ready to start treatment; not having enough time for treatment and concerns about cost.¹ In addition, some studies suggest that understanding cultural practices such as traditional healing, and acknowledgement of cultural divergence between clinicians and patients may impact intervention access for participants of Indigenous descent.¹

The USPSTF found no evidence to suggest differences in intervention effectiveness by sex, race, or ethnicity.¹

Screening Intervals

The USPSTF found no evidence to suggest an optimal screening interval for unhealthy alcohol use in adults.

Suggestions for Practice Regarding I Statement

In deciding whether to screen or provide behavioral counseling interventions for alcohol use, clinicians caring for adolescents should consider the following:

Potential Preventable Burden

In a 2023 National Survey on Drug Use and Health among youth age 12 to 17 years, 6% of boys and 7.9% of girls reported alcohol use in the past month.¹¹ According to the 2021 Youth Risk Behavior Survey, current use of alcohol in high school students decreased from 29.2% in 2019 to 22.7 percent in 2021, decreases were consistent in males and females and among Black, White, and Hispanic populations.¹²

Potential Harms

Potential harms of screening for unhealthy alcohol use in adolescents include stigma, discrimination, labeling, privacy concerns, and interference with the patient-clinician relationship. The USPSTF did not find evidence examining these potential harms.

Current Practice

According to the 2015-2016 National Ambulatory Medical Care Survey, 72% of primary care physicians report screening their patients for alcohol misuse and of those who screen, over half (68%) report annual screening or screening at every healthcare visit.¹³ In addition, 65% of physicians report they often or always provide a brief intervention for patients who screen positive for alcohol misuse.¹³ In a recent systematic review, common reported barriers to implementing alcohol screening and brief interventions among clinicians included time constraints for screening, lack of time to counsel in the event of a positive screen, and lack of adequate training on screening instruments.¹⁴

Additional Tools and Resources

The Centers for Disease Control and Prevention’s Guide on Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use is designed to help clinicians and others implement alcohol interventions into primary care.¹⁵

The National Institute on Alcohol Abuse and Alcoholism has developed a variety of evidence-based resources for clinicians and others focused on alcohol screening and interventions.^16,17

Other Related USPSTF Recommendations

USPSTF recommendations include screening for unhealthy drug use,¹⁸ and interventions to reduce use of illicit drugs¹⁹ and tobacco^20,21 in children, adolescents, and adults.  

This recommendation updates and is consistent with the 2018 USPSTF recommendation on screening for alcohol use in adolescents and adults.

Scope of Review

The USPSTF commissioned a systematic review¹ to evaluate the benefits and harms of screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults. The review updates the USPSTF’s previous recommendation. In 2018 the USPSTF concluded that numerous brief screening instruments can detect unhealthy alcohol use with acceptable sensitivity and specificity in primary care settings in adults. Given these findings, the current review focused on screening instruments that are relevant to the US primary care setting and were under development at the time of the previous review.

Accuracy of Screening Tests

Adults

Due to established evidence that available screening instruments can detect UAU with acceptable sensitivity and specificity in primary care settings in adults, the USPSTF focused on USAUDIT and USAUDIT-C due to their potential relevance to the US population but found limited evidence on the accuracy of these screening instruments to detect UAU in adults.

In 2 studies (n=632) reporting the accuracy of the USAUDIT to identify UAU in US college students, prevalence of likely AUD among recruited participants ranged from 40-50%.¹ Sensitivity to detect AUD ranged from 0.61 (95% CI, 0.52 to 0.69) to 0.72 (95% CI, 0.64 to 0.78) and specificity ranged from 0.80 (95% CI, 0.74 to 0.84) to 0.86 (95% CI, 0.78 to 0.91).¹ The author-reported optimal cutoff varied, with one study reporting an optimal cutoff of ≥8 and the other reporting an optimal cutoff of ≥13.¹ In the same 2 studies reporting the accuracy of the USAUDIT-C to detect AUD, sensitivity ranged from 0.61 (95% CI, 0.53 to 0.69) to 0.79 (95% CI, 0.71 to 0.85) and specificity ranged from 0.57 (95% CI, 0.48 to 0.65) to 0.79 (95% CI, 0.73 to 0.83).¹ Both studies reported ≥7 as the optimal cutoff.¹

Adolescents

Thirteen studies (N= 173,680) reported on the accuracy of 12 screening instruments to identify UAU in adolescents.¹ Most of the studies took place in the US or included populations generalizable to US primary care settings.¹ AUDIT was the most commonly used screening instrument and past use frequency was most commonly assessed.¹ Overall, the USPSTF found adequate evidence that available screening instruments can detect AUD in adolescents. Screening instruments for UAU in this population were limited in quantity with lower sensitivity and specificity measures.¹ Further, several studies included participants with a high prevalence of alcohol conditions such alcohol abuse, dependence, or heavy drinking problems limiting generalizability of study findings to the overall US adolescent population.¹ AUD is uncommon in adolescents, therefore identifying any alcohol use or full spectrum UAU likely enhances relevance to the general US adolescent population.¹

Three studies (n=2,332) reported accuracy of AUDIT to detect AUD.¹ All studies reported the standard cutoff of >=8; at this cutoff, sensitivity ranged from 0.54 (95% CI, 0.38 to 0.69) to 0.71 (95% CI, 0.57 to 0.82) and specificity ranged from 0.84 (95% CI, 0.78 to 0.89) to 0.97 (95% CI, 0.95 to 0.98).¹

Two of the three studies (n=820) also reported accuracy of the full spectrum of UAU using AUDIT.¹ Using author reported cutoffs (≥5 in one study and ≥6 in the other), sensitivity ranged from 0.79 (95% CI, 0.66 to 0.87) to 0.93 (95% CI, 0.89 to 0.96) and specificity ranged from 0.77 (95% CI, 0.73 to 0.81) to 0.79 (95% CI, 0.73 to 0.85).¹ Some studies reported the accuracy of screening instruments detecting non-standard alcohol use conditions including the largest included study (n=166,165).¹

Benefits of Counseling Interventions

Adults

The USPSTF reviewed 79 trials to assess the benefits of interventions to reduce UAU in adult populations.¹ Across 79 trials (N=40,486) more than half (59%) were in the US and nearly half (44%) in primary care settings. In pooled analysis, participants in the intervention groups reduced alcohol consumption by an average of 1.6 drinks per week compared to control groups (mean difference [MD], -1.6 [95% CI, -2.2 to -1.0]; 38 studies [41 groups analyzed], n=17,816; I²=62%).¹The median reduction in drinks per week was 3.6 drinks among the intervention groups and 2.3 drinks among the control groups.¹ In addition, interventions that reduce UAU were also associated with a 35% reduction in the odds of exceeding recommending drinking limits and a 26% reduction in the odds of any heavy episodic drinking in the follow-up period (exceeding limits: OR, 0.65 [95% CI, 0.55 to 0.76], 17 trials [19 groups included in the analysis], N=10,163; I²=57%; any heavy episodic drinking: OR, 0.74 [95% CI, 0.64 to 0.85], 16 trials [18 groups included in the analysis], N=10,130; I²=40%).¹ The USPSTF also reviewed evidence reporting the odds of abstinence more than doubled among pregnant women with brief interventions (OR, 2.26 [95% CI, 1.25 to 4.07]; number needed to treat, 6 based on control group median of 62.3%).¹ Overall interventions reduced weekly alcohol consumption and increased the likelihood of drinking within recommended limits and avoiding heavy episodic drinking in adults.¹

Across 23 trials reporting the consequences of alcohol use (i.e., going to school or work while intoxicated, getting into fights), pooled group differences were small and statistically significant when limited to young adults (standardized mean difference [SMD], -0.07 [95% CI, -0.13 to -0.01] 14 RCTs, N=6,305, I²=0%, among young adults).¹ The USPSTF also reviewed epidemiologic evidence on the association between excessive alcohol consumption and a range of adverse health outcomes including hypertension, liver disease, cancer, and all-cause mortality.¹

Adolescents

Across 5 trials in adolescents (N=2,964) on the benefits of counseling to reduce UAU, 4 were conducted in US primary care settings.¹ Of the 4 US based studies, 3 did not demonstrate statistical significance.¹ Generally studies reported different outcome measures and results varied.

One study (N=1871) reported fewer alcohol-related diagnoses in the electronic medical record after 7 years among youth who screened positive for alcohol, drug use, or depression symptoms in practices that implemented routine SBIRT (OR, 0.69 [95% CI, 0.51 to 0.94], p=0.017; 4.8% in the IG vs. 7.8% in the CG).¹ This study did not directly measure alcohol use and included mood symptoms.¹ A 2nd trial of Swiss high school students who could legally purchase alcohol found high risk but not medium risk youth reported reduced alcohol use.¹ This was the only trial in which youth could legally purchase alcohol.¹ The applicability of these findings to US youth with UAU is uncertain.¹

Harms of Screening and Treatment

No identified studies reported on the harms of alcohol screening in adults or adolescents. Potential harms of screening include stigma, discrimination, privacy concerns, negative impacts on the patient-provider relationships, and risk of legal action during pregnancy.

No identified studies reported on the harms of alcohol interventions in adolescents.¹ The USPSTF reviewed 7 studies (n= 3991) on the harms of interventions to reduce UAU in adults and none reported any adverse events in the intervention or control groups.¹

To fulfill its mission to improve health by making evidence-based recommendations for preventive services, the USPSTF routinely highlights the most critical evidence gaps for making actionable preventive services recommendations. The USPSTF often needs additional evidence to create the strongest recommendations for everyone and especially for people with the greatest burden of disease. This table summarizes key bodies of evidence needed for the USPSTF to make recommendations for Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults. Studies suggest gaps in use of standardized screening tools in current practice, leading to missed opportunities to intervene in patients with UAU.¹ Future research optimizing implementation of this recommendation is needed.

1. Studies are needed on the effectiveness of interventions to reduce unhealthy alcohol use in adolescents:
   • Studies should have standard outcomes (“such as abstinence, heavy episodic drinking, drinks per drinking day, and drinks per week or per month (depending on the age of the participants”).
   • Studies should focus on populations who screen positive for unhealthy alcohol use (rather than including only adolescents seeking treatment).
   • Studies can address multiple substances but the aim should include screening and interventions for UAU. Findings should be separately reported for UAU.
2. Studies are needed on the accuracy of the USAUDIT and USAUDIT-C screening instrument to detect UAU in adults.
3. Studies are needed on the effectiveness of interventions to reduce unhealthy alcohol use in adults:
   • Studies are needed in populations that are underrepresented in current research.
   • Studies are needed that demonstrate effective interventions customized to patient populations.
   • Studies are needed in populations who experience increased rates of UAU.

The Department of Defense/Veterans Health Administration,22 the Office of the Surgeon General,²³ the NIAAA,¹⁷ and the CDC,¹⁵ agree with the 2018 USPSTF recommendation that adult patients should be routinely screened for at-risk drinking and brief counseling should be provided to patients who are determined to have unhealthy alcohol use behaviors. The American Academy of Pediatrics recommends that pediatricians screen with a formal, validated tool and that they be familiar with SBIRT practices.²⁴

The American College of Obstetricians and Gynecologists recommends that all women should be screened before pregnancy and in their first trimester of pregnancy with a validated tool and that providers should offer a brief intervention to all pregnant women using alcohol.²⁵

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2. Esser MB, Leung G, Sherk A, et al. Estimated deaths attributable to excessive alcohol use among US adults aged 20 to 64 years, 2015 to 2019. JAMA Netw Open. 2022;5(11):e2239485-e2239485.
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