Make Alcohol Screening More of a Clinical Priority

 I'm Dr Kenny Lin, a family physician and associate director of the Lancaster General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.

Kenneth W. Lin, MD, MPH

In medical school a quarter of a century ago, I remember being told regularly that having a couple of glasses of wine with dinner was not harmful and might even be good for the heart. To identify unhealthy use of alcohol in the outpatient setting, I used the CAGE (Cut down, Annoyed, Guilty feeling, and Eye-opener) questionnaire: A “yes” answer to the Eye-opener question or at least two of the others was considered a positive result. I saw quite a few hospitalized patients with alcohol withdrawal and complications from cirrhosis, but in the office, drinking alcohol usually took a back seat to using tobacco or taking drugs.

Times have changed. A growing consensus is emerging that low levels of alcohol use do not have protective health effects, and the only safe level of alcohol intake is none. Meanwhile, behaviors appear headed in the other direction. Data from the United States show increases in any consumption of alcohol and heavy drinking from 2018 to 2022 and an alarming 30% rise in alcohol-related deaths, from 138,000 in 2016 to 178,000 in 2021. 

Concerned that clinicians are underdiagnosing patients with alcohol use disorder (AUD), either because we don’t ask or patients are reluctant to disclose their drinking, the American College of Physicians recently urged its members to “increase their knowledge of the health effects of varying patterns of alcohol use and interventions to address excessive alcohol use and AUD.”

Personally, I classify myself as a lifelong light drinker; when not on vacation, I typically consume one or two alcoholic beverages a month. What do I tell patients whose alcohol use resembles mine or is within the low-risk thresholds of two drinks per day for men or one drink per day for women? The message is not so different from what I have been saying to my pregnant patients for years: No amount of alcohol consumption is 100% safe, and drinking less is less risky than drinking more.

My current screening practice generally aligns with guidelines from the US Preventive Services Task Force and other experts. I’ve discarded the CAGE in favor of a single question: How many times in the past year have you had five (four for women) or more drinks in a day? If the patient says one or more, I administer the Alcohol Use Disorders Identification Test (AUDIT). Depending on their score, some patients will require only brief (5-minute) counseling; others I will offer evidence-based medications for AUD, and a few I may refer to formal AUD treatment programs. 

Competing clinical priorities, unconscious biases (“this patient can’t possibly have a drinking problem”), and disparate resources can interfere with evidence-based care. A national study found that Asian and Black patients, and adults older than 50 years, were substantially less likely to be asked about alcohol use than White and younger adults, respectively. In a study of 67 primary care practices in Virginia, patients with multiple physical and mental health conditions were more likely to have unhealthy drinking habits, but were less likely to be screened for alcohol use, than patients without chronic conditions. Rural areas have higher rates of hospitalizations and readmissions for health problems related to drinking than urban areas, suggesting that rural patients have less access to treatment for AUD.

A recent analysis raised the possibility that the diabetes and weight loss drugs semaglutide and liraglutide could be viable treatments for AUD. More studies are needed, but in my mind, the bigger problem is that family physicians can’t treat patients with drinking problems without diagnosing them first. Practice facilitation interventions can help redesign workflows to improve rates of screening, counseling, prescribing, and referrals for unhealthy alcohol use in primary care. Not only is alcohol screening and counseling the right thing to do for our patients, but practices can bill for these preventive services, which insurers generally cover without patient cost-sharing.

https://www.medscape.com/viewarticle/bottoms-down-make-alcohol-screening-more-clinical-priority-2024a1000otm