Most American adults drink alcohol, and 45% binge drink
-- five or more drinks per occasion for men, 4 or more drinks per occasion for women -- at least monthly. There is evidence that any level of alcohol use is associated with increased relative risk of morbidity and mortality, and the latest estimates indicate one in eight American adult deaths (ages 20 to 64) are attributed to alcohol. In the state of New Mexico, which has the highest rate of alcohol-related mortality nationwide, one in five adult deaths are attributable to alcohol. Importantly, reductions in alcohol consumption -- even without abstaining completely -- are associated with clinically meaningful improvements in health and functioning.
As such, the medical community should be concerned with alcohol's impact on health/well-being and encourage all patients to reduce their drinking. Screening for alcohol use in primary care settings is increasingly common, but what happens when patients actually endorse alcohol use? And, what happens when patients explicitly ask providers for support in reducing drinking? In our experience, this is where the medical community has failed the millions of Americans who drink alcohol.
Screening for problems related to alcohol use is a critical first step.
The first step is asking patients about alcohol use. There are many validated screening tools and guides for how to assess amount and frequency of alcohol consumption. But what actually happens in clinical practice? One of us (Witkiewitz) recently visited a healthcare provider who looked down at her tablet nervously while asking, "Do you drink alcohol?" I replied, "Yes." The provider followed up by saying: "So, like, one or two drinks, no more than a few times per week?" I was not asked the question in a way that I could answer, and there were no follow-up questions. Unfortunately, lack of follow-up after an initial screen about alcohol is the most common outcome in healthcare settings.
We recommend all healthcare providers take alcohol screening as seriously as other screenings, and inquire about alcohol consumption using nonjudgmental, open-ended questions. It is helpful to be more concerned with how alcohol fits into one's health and well-being rather than being overly concerned with the amount of consumption. For example, consider trying, "How does alcohol fit into your life and your health?" or, "We know that alcohol can have an impact on sleep, blood pressure, pain, etc. -- how does alcohol impact your health?" The National Institute on Alcohol Abuse and Alcoholism's (NIAAA) Health Professional's Core Resource on Alcohol
provides step-by-step instructions on how to screen for alcohol use and what to do if somebody screens positive. You can also earn free continuing medical education credits for moving through the online resource.
What do you do if somebody indicates alcohol is causing problems in their life?
The second step is acting on the screening information if there is a concern that alcohol is negatively impacting a patient's health and well-being. An example of what not to do: one of us (Carlon) was recently providing psychotherapy to a patient who was seeking alcohol specialty treatment services for severe alcohol use disorder. The patient reduced his drinking from 15 drinks per day to three drinks per day during the first part of treatment, but he was hoping for more support to reduce further or abstain completely. I encouraged the patient to talk with his healthcare provider about medications for alcohol use disorder and obtained a release of information from the patient to speak directly with the healthcare provider about potentially prescribing naltrexone (Revia or Vivitrol). The healthcare provider responded that he could not prescribe naltrexone because it required specialized licensure and training, and he argued that the patient needed to be admitted to inpatient detoxification and rehabilitation.
This was all unequivocally false. Prescribing medications for alcohol use disorder does not require specialized licensure or training, and we know that outpatient treatment with psychotherapy and medications can be extremely effective -- as effective as inpatient treatment
-- at much lower cost and less disruption to the patient's life.
Healthcare providers have a range of tools available to support patients who are experiencing difficulties related to alcohol use. Laboratory tests can detect recent heavy drinking or determine whether alcohol use is impacting liver function. Talking openly and non-judgmentally about alcohol use can be a brief intervention, in and of itself. If the patient is interested in exploring treatment for alcohol use, a number of medication and non-medication options are available. Naltrexone, acamprosate, and disulfiram are all FDA approved for alcohol use; none of these prescriptions require specialized training or licensure to prescribe safely and effectively. Naltrexone can be prescribed via an injectable, daily dosing, or on an as-needed basis to reduce heavy drinking. Disulfiram should only be prescribed for those who want to abstain completely from alcohol. Topiramate, baclofen, varenicline (Chantix), and gabapentin are commonly used off-label; varenicline might be particularly helpful for heavy drinkers who also smoke cigarettes. The NIAAA Health Professional's Core Resource on Alcohol (also mentioned above) and the American Psychiatric Association Practice Guideline provides more information on these medications. If a patient is interested in non-medication options, there are also a plethora of potentially helpful alternatives to connect them with. The NIAAA's Alcohol Treatment Navigator provides an overview of different treatments and links for treatment programs throughout the U.S. For patients who may be contemplating changing their drinking, the free, online Rethinking Drinking tool provides worksheets and self-paced tips for drinking reductions and the Kaiser Permanente patient decision aid offers a range of resources. There are also a number of mutual support groups, many of which offer online programs for those who cannot access in-person groups.
The burden of alcohol use on American adults is immense. Nonjudgmental, open, and science-based screening and support for alcohol problems in medical settings could alleviate this burden.
Katie Witkiewitz, PhD, is a distinguished professor of psychology and director of the Center on Alcohol, Substance Use, and Addiction at the University of New Mexico. She is also a licensed clinical psychologist. Hannah Carlon, MS, is a doctoral student in clinical psychology and graduate student coordinator of the @UNM Alcohol Specialty Clinic at the University of New Mexico.
