The U.S. Preventive Services Task Force (USPSTF) grades its recommendations (A, B, C, D, or I) and the quality of the overall evidence for a service (good, fair, poor). The definitions of these grades can be found at the end of the "Major Recommendations" field.
The USPSTF recommends screening and behavioral counseling interventions to reduce alcohol misuse (see Clinical Considerations below) by adults, including pregnant women, in primary care settings. B recommendation.
The USPSTF found good evidence that screening in primary care settings
can accurately identify patients whose levels or patterns of alcohol consumption
do not meet criteria for alcohol dependence, but place them at risk for
increased morbidity and mortality, and good evidence that brief behavioral
counseling interventions with follow-up produce small to moderate reductions in
alcohol consumption that are sustained over 6- to 12-month periods or longer.
The USPSTF found some evidence that interventions lead to positive health
outcomes 4 or more years post-intervention, but found limited evidence that
screening and behavioral counseling reduce alcohol-related morbidity. The
evidence on the effectiveness of counseling to reduce alcohol consumption during
pregnancy is limited; however, studies in the general adult population show that
behavioral counseling interventions are effective among women of childbearing
age. The USPSTF concluded that the benefits of behavioral counseling
interventions to reduce alcohol misuse by adults outweigh any potential harms.
The USPSTF concludes that the evidence is insufficient to recommend for or
against screening and behavioral counseling interventions to prevent or reduce
alcohol misuse by adolescents in primary care settings. I
recommendation.
The USPSTF found limited evidence evaluating the effectiveness of
screening and behavioral counseling interventions in primary care settings to
prevent or reduce alcohol misuse by adolescents. The USPSTF concluded that the
evidence is insufficient to assess the potential benefits and harms of screening
and behavioral counseling interventions in this population.
Clinical Considerations
- Alcohol misuse includes "risky/hazardous" and "harmful" drinking that places individuals at risk for future problems. "Risky" or "hazardous" drinking has been defined in the United States as more than 7 drinks per week or more than 3 drinks per occasion for women, and more than 14 drinks per week or more than 4 drinks per occasion for men. "Harmful drinking" describes persons who are currently experiencing physical, social, or psychological harm from alcohol use but do not meet criteria for dependence. Alcohol abuse and dependence are associated with repeated negative physical, psychological, and social effects from alcohol. The USPSTF did not evaluate the effectiveness of interventions for alcohol dependence because the benefits of these interventions are well established and referral or specialty treatment is recommended for those meeting the diagnostic criteria for dependence.
- Light to moderate alcohol consumption in middle-aged or older adults has been associated with some health benefits, such as reduced risk for coronary heart disease. Moderate drinking has been defined as 2 standard drinks (e.g., 12 ounces of beer) or less per day for men and 1 drink or less per day for women and persons older than 65, but recent data suggest comparable benefits from as little as 1 drink 3 to 4 times a week.
- The Alcohol Use Disorders Identification Test (AUDIT) is the most studied
screening tool for detecting alcohol-related problems in primary care settings. It is sensitive for detecting alcohol misuse and abuse or dependence and can be used alone or embedded in broader health risk or lifestyle assessments. The 4-item CAGE (feeling the need to Cut down, Annoyed by criticism, Guilty about drinking, and need for an Eye-opener in the morning) is the most popular screening test for detecting alcohol abuse or dependence in primary care. The TWEAK, a 5-item scale, and the T-ACE are designed to screen pregnant women for alcohol misuse. They detect lower levels of alcohol consumption that may pose risks during pregnancy. Clinicians can choose screening strategies that are appropriate for their clinical population and setting. Screening tools are available at the National Institute on Alcohol Abuse and Alcoholism Web site: http://www.niaaa.nih.gov/publications/instable.htm.
- Effective interventions to reduce alcohol misuse include an initial counseling session of about 15 minutes, feedback, advice, and goal-setting. Most also include further assistance and follow-up. Multi-contact interventions for patients ranging widely in age (12-75 years) are shown to reduce mean alcohol consumption by 3 to 9 drinks per week, with effects lasting up to 6 to 12 months after the intervention. They can be delivered wholly or in part in the primary care setting, and by 1 or more members of the health care team, including physician and non-physician practitioners. Resources that help clinicians deliver effective interventions include brief provider training or access to specially trained primary care practitioners or health educators, and the presence of office-level systems supports (prompts, reminders, counseling algorithms, and patient education materials).
- Primary care screening and behavioral counseling interventions for alcohol misuse can be described with reference to the 5-As behavioral counseling framework: assess alcohol consumption with a brief screening tool followed by clinical assessment as needed; advise patients to reduce alcohol consumption to moderate levels; agree on individual goals for reducing alcohol use or abstinence (if indicated); assist patients with acquiring the motivations, self-help skills, or supports needed for behavior change; and arrange follow-up support and repeated counseling, including referring dependent drinkers for specialty treatment. Common practices that complement this framework include motivational interviewing, the 5 Rs used to treat tobacco use, and assessing readiness to change.
- The optimal interval for screening and intervention is unknown. Patients with past alcohol problems, young adults, and other high-risk groups (e.g., smokers) may benefit most from frequent screening.
- All pregnant women and women contemplating pregnancy should be informed of the harmful effects of alcohol on the fetus. Safe levels of alcohol consumption during pregnancy are not known; therefore, pregnant women are advised to abstain from drinking alcohol. More research into the efficacy of primary care screening and behavioral intervention for alcohol misuse among pregnant women is needed.
- The benefits of behavioral intervention for preventing or reducing alcohol
misuse in adolescents are not known. The CRAFFT questionnaire was recently
validated for screening adolescents for substance abuse in the primary care
setting. The benefits of screening this population will need to be evaluated
as more effective interventions become available in the primary care setting.
Definitions
Strength of Recommendations
The Task Force grades its recommendations according to one of 5
classifications (A, B, C, D, I) reflecting the strength of evidence and
magnitude of net benefit (benefits minus harms):
A
The USPSTF strongly recommends that clinicians provide [the
service] to eligible patients. The USPSTF found good evidence that [the service]
improves important health outcomes and concludes that benefits substantially
outweigh harms.
B
The USPSTF recommends that clinicians provide [the service] to
eligible patients. The USPSTF found at least fair evidence that [the service]
improves important health outcomes and concludes that benefits outweigh harms.
C
The USPSTF makes no recommendation for or against routine provision of [the
service]. The USPSTF found at least fair evidence that [the service] can improve
health outcomes but concludes that the balance of benefits and harms is too
close to justify a general recommendation.
D
The USPSTF recommends against routinely providing [the service] to
asymptomatic patients. The USPSTF found at least fair evidence that [the
service] is ineffective or that harms outweigh benefits.
I
The USPSTF concludes that the evidence is insufficient to recommend for or
against routinely providing [the service]. Evidence that [the service] is
effective is lacking, of poor quality, or conflicting and the balance of
benefits and harms cannot be determined.
Strength of Evidence
The USPSTF grades the quality of the overall evidence for a service on a
3-point scale (good, fair, poor):
Good
Evidence includes consistent results from well-designed, well-conducted
studies in representative populations that directly assess effects on health
outcomes.
Fair
Evidence is sufficient to determine effects on health outcomes, but the
strength of the evidence is limited by the number, quality, or consistency of
the individual studies, generalizability to routine practice, or indirect nature
of the evidence on health outcomes.
Poor
Evidence is insufficient to assess the effects on health outcomes because of
limited number or power of studies, important flaws in their design or conduct,
gaps in the chain of evidence, or lack of information on important health
outcomes.