in progress

Final Research Plan

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

May 16, 2024

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.

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Figure 1 is the analytic framework that depicts the five Key Questions (KQ) to be addressed in the systematic review. The figure illustrates how screening for unhealthy alcohol use, followed by behavioral counseling interventions, may result in a reduction of alcohol use, other risky behaviors, and morbidity/morality, as well as improve social and legal outcomes (KQ1). Additionally, the figure illustrates the relationship between screening instruments (including evaluation of their accuracy [KQ2]) and potential harms of screening procedures (KQ3). The figure also shows Key Question 4 that examines how receipt of behavioral counseling interventions may lead to changes in behavioral (e.g., alcohol use) and health outcomes (e.g., morbidity/mortality). Finally, the figure depicts whether behavioral counseling interventions are associated with any harms (KQ5).

1. a. Does primary care screening for unhealthy alcohol use in adolescents and adults reduce alcohol use or improve other risky behaviors?
   b. Does primary care screening for unhealthy alcohol use in adolescents and adults reduce morbidity or mortality or improve other health, social, or legal outcomes?
2. What is the accuracy of selected commonly used instruments to screen for unhealthy alcohol use in adolescents and adults?
3. What are the harms of screening for unhealthy alcohol use in adolescents and adults?
4. a. Do counseling interventions to reduce unhealthy alcohol use reduce alcohol use or improve other risky behaviors in screen-detected individuals?
    b. Do counseling interventions to reduce unhealthy alcohol use reduce morbidity or mortality or improve other health, social, or legal outcomes in screen-detected individuals?
5. What are the harms of interventions to reduce unhealthy alcohol use in screen-detected individuals?

Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework.

  1. What is the association between reduced alcohol use and health outcomes?
  2. What are the barriers and facilitators to equitable access to interventions, and do they vary among different racial and ethnic groups or by socioeconomic status, geography, age, and other sociocultural variables?

Health equity will be considered throughout the review using several approaches. For Key Questions, we will describe the population and intervention characteristics of the included studies to assess the degree to which the evidence is representative of diverse populations. We will also examine evidence separately across age groups (adolescents, young adults, general adult populations, and older adults) and among individuals who are pregnant. In addition, we will explore the extent to which interventions incorporate elements to ameliorate the impact of social risk factors such as housing and food insecurity, financial strain, lack of transportation, caregiver support needs, and other medical needs. We will also examine selected subgroup or stratified analyses reported in the included studies to explore whether broad implementation might reduce or exacerbate inequities in unhealthy alcohol use and related morbidity and mortality. Specific analyses of interest will be those stratified by race, ethnicity, sex, gender, physical and intellectual disability, and socioeconomic status. Finally, we will include text in the Introduction exploring what is known about how structural and social determinants of health affect risk for unhealthy alcohol use and access to treatment in the United States.

The Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Review. Criteria are overarching as well as specific to each of the Key Questions.

Category Included Excluded
Aim Screening for unhealthy alcohol use and interventions for unhealthy alcohol use, with or without addressing other substances or behaviors. See “Condition” for the definition of unhealthy alcohol use. Studies in which the only aim is targeting another behavior (e.g., drug or tobacco use) such that change in alcohol use is not a stated aim, even if it is a reported outcome
Condition Unhealthy alcohol use, including:
  • Risky or hazardous use: consumption of alcohol above recommended daily, weekly, or per occasion amounts; consumption levels that increase the risk for health consequences (e.g., according to national guidelines or relevant professional societies)
  • Harmful use: a pattern of drinking that is already causing damage to health; damage may be either physical (e.g., liver damage from chronic drinking) or mental (e.g., depressive episodes secondary to drinking)
  • A diagnosis of an alcohol use disorder (e.g., according to Diagnostic and Statistical Manual of Mental Disorders [DSM] or International Classification of Diseases [ICD] diagnostic systems)
  
Population All KQs: Adolescents and adults (age ≥12 years), including individuals who are pregnant

KQs 1–3: Studies whose participants are not selected on the basis of alcohol use or a related behavior or condition

KQs 4, 5: Studies in which at least 50% of the enrolled sample is recruited via population-based screening, and at least 50% do not meet criteria for severe alcohol use disorder or alcohol dependence

 Studies in which >50% of participants are:
  • Treatment-seeking individuals (including those responding to recruitment advertising)
  • Persons with concomitant psychotic disorders (e.g., schizophrenia)
  • Persons presenting in an emergency setting for alcohol-related issues (e.g., motor vehicle injury)
  • Other groups not generalizable to primary care (e.g., psychiatric inpatients, persons who are court-mandated to treatment, and incarcerated persons)
  • KQs 4, 5: Persons with severe alcohol use disorder or dependent alcohol abuse (or >50% of the enrolled sample)
Screening KQs 1, 3, 4, 5: Screening for alcohol use using a brief standardized instrument or set of questions that is conducted in person or via telephone, mail, or electronically (not limited to the tools listed for KQ2)

KQ 2: Accuracy of screening instruments will be limited to the following instruments, which include the most widely used and feasible for application in primary care in adolescents, and new versions of previously established instruments adapted to standard drink size and hazardous drinking guidelines in the United States:

  • All populations: U.S. Alcohol Use Disorders Identification Test (USAUDIT), USAUDIT-Concise (USAUDIT-C), version optimized for the United States
  • Adolescents: National Institute on Alcohol Abuse and Alcoholism (NIAAA) two-item screening test, Screening to Brief Intervention (S2BI), Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) or comparable
  • Studies without any screening instruments or question(s)
  • Laboratory tests
  • For KQ2 only, other screening tests (including the AUDIT, AUDIT-C using traditional drink size guidelines); the previous review determined that screening tools in adults have adequate accuracy to detect unhealthy alcohol use with high strength of evidence; however, the USAUDIT and USAUDIT-C were under development at the time of the previous review
Interventions Counseling to reduce unhealthy alcohol use, with or without referral. Counseling interventions can vary in their approach (e.g., 12-step program, cognitive behavioral therapy, or motivational enhancement therapy), specific strategies, delivery method (e.g., face-to-face, electronic, individual, group-based, or telemedicine), duration of contact, and the number of contacts. Interventions may address other substances in addition to alcohol, but alcohol use reduction must be a primary aim of the study.
  • Financial incentive
  • Vocational rehabilitation
  • Community-based media or policy interventions
  • Interventions to prevent initiation of use among nonusers
  • Pharmacotherapy
  • Interventions conducted among peers with preexisting relationships (e.g., students at the same high school)
Comparators KQs 1, 3: No screening or usual care

KQ 2: Comparison with reference standard (i.e., structured or semistructured clinical interview)

KQs 4, 5:
  • No intervention
  • Usual care
  • Waitlist
  • Attention control (e.g., intervention is similar in format and intensity but on a different content area)
  • Minimal intervention (e.g., no more than one single brief contact per year, brief written materials such as pamphlets)
 Active intervention  (e.g., comparators with a reasonable expectation of affecting change in alcohol consumption)
Setting KQs 1–3: Broad-based, general settings, including: primary care; prenatal or obstetrics/gynecology; geriatric ambulatory care; subspecialty medical settings other than addiction or mental health (e.g., orthopedic, allergy); research clinics; broad community or school settings (e.g., Special Supplemental Nutrition Program for Women, Infants, and Children [WIC] or college freshman orientation); may include electronic or computer-based screening

KQs 4, 5: Broad-based, general settings as described above, or mental health, addiction, or substance specialty settings. Screening to identify eligible participants must take place in broad-based, general settings as described above		 Screening that takes place in:
  • Behavioral/mental health clinic
  • Substance abuse treatment center
  • Emergency department/trauma center
  • Worksites
  • Inpatient/residential facilities
  • Other institutions (e.g., correctional facility)

Screening or interventions that take place in:

  • Worksites
  • Inpatient/residential facilities
  • Other institutions (e.g., correctional facility)
  • Classrooms, or target the school environment (interventions that are conducted in school-based health clinics, entirely online, or in the community but participants are recruited from schools are included)
Outcomes KQs 1a, 4a:
  • Alcohol use (required), self-report and/or biologic measures, including:
    • Frequency and/or quantity of alcohol use
    • Abstinence (use/no use)
    • Severity of alcohol use disorder (reported as an index measured by a standardized questionnaire, such as the Short Inventory of Problems, Addiction Severity Index, or the Severity of Dependence Scale)
    • Meeting criteria for alcohol use disorder
  • Other risky behaviors (e.g., other illicit drug use, risky sexual behaviors, perpetuating or experiencing violence)
KQs 1b, 4b:
  • All-cause mortality
  • Alcohol-related mortality (intentional and unintentional)
  • Symptoms and conditions associated with unhealthy alcohol use (e.g., mental health symptoms/disorders; alcohol-related liver problems, including fatty liver disease, alcoholic hepatitis, and alcoholic cirrhosis; cancer; cardiovascular disease, such as cardiomyopathy; neuropathy; cognitive impairment; gastritis; gastric ulcers; pancreatitis; anemia; and injuries, assaults, and accidents)
  • Acute healthcare use: visits to emergency department and inpatient stays
  • Obstetrical/perinatal/neonatal outcomes (e.g., perinatal mortality, preterm labor/delivery, low birth weight, placental abruption, intrauterine growth restriction, preeclampsia, antepartum or postpartum hemorrhage, gestational hypertension, decreased neonate length/head circumference, neonate neurobehavioral effects, congenital anomalies, neonatal abstinence syndrome, neonatal intensive care unit admission, decreased length of neonate hospitalization, fetal alcohol spectrum disorders)
  • Quality of life
  • Alcohol-related problems, such as legal problems (arrests or DUI citations), social and family relations, employment, and school/educational outcomes
KQ 2: Sensitivity and specificity or data to calculate them

KQs 3, 5:
  • Serious harms at any time point after the screening or intervention began (e.g., death, seizure, cardiovascular event, or other medical issue requiring urgent medical treatment; serious obstetrical/perinatal/neonatal complication)
  • Demoralization due to failed quit attempt
  • Psychological harms (e.g., stigma, shame, labeling, and/or discrimination)
  • Privacy issues (e.g., insurability status)
  • Job loss
  • Lack of trust or interference with the doctor-patient relationship
  • Attitudes, knowledge, and beliefs related to alcohol use
  • Intention to change behavior
  • Intervention participation/compliance
  • Alcohol use initiation among adolescents who have not used alcohol
Outcome assessment timing At least 6 months after baseline measurement (except for studies in pregnant women, for which shorter followup times will be included)  
Study design KQs 1, 3: Studies that compare individuals who receive screening with those receiving no screening or usual care, including randomized, controlled trials and nonrandomized controlled trials (i.e., longitudinal studies with concurrent comparisons groups)

KQ 2: Studies of screening accuracy reporting sensitivity and specificity compared with a structured or semistructured clinical interview

KQs 4, 5: Randomized, controlled trials		 Other study designs
Country Studies conducted in countries categorized as "Very High" on the 2021 Human Development Index (as defined by the United Nations Development Programme) Studies conducted in countries that are not categorized as "Very High" on the 2021 Human Development Index
Publication date Studies whose primary results were published from 1985 to present Studies whose primary results were published prior to 1985
Publication language English Languages other than English
Quality Fair or good quality Poor quality (according to design-specific USPSTF criteria)

Abbreviations: DUI=driving under the influence; KQ=key question; USPSTF=U.S. Preventive Services Task Force.

The draft Research Plan was posted for public comment on the U.S. Preventive Services Task Force website from February 1, 2024, to February 28, 2024. In response to public comments, we added an additional contextual question to examine the barriers and facilitators of screening and treatment for selected populations such as those defined by age, race, ethnicity, socioeconomic status, and geography. We also added some additional outcomes, some additional social determinants of health to note if included in interventions, added additional populations of interest for seeking study-reported subgroup analyses, and clarified wording in several sections, including noting that we plan to include studies that recruit from schools and universities if the intervention is online or in a community or university-wide setting, but we will exclude classroom-based studies and those that target the school environment.