Original Research

Primary Care Physicians’ Views on Screening and Management of Alcohol Abuse Inconsistencies with National Guidelines

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BACKGROUND: The effects of patients’ abuse of and dependence on alcohol are well known, but screening for problem drinking by primary care physicians has been limited. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends that all patients be screened for alcohol use, all users be screened with the CAGE questionnaire, and all nondependent problem drinkers be counseled. We evaluated primary care physicians’ screening methods for alcohol use and their management of problem drinkers to determine if they were following the NIAAA guidelines.

METHODS: We mailed a questionnaire to 210 internists and family physicians to assess their alcohol screening and management methods.

RESULTS: Only 64.9% of the respondents reported screening 80% to 100% of their patients for alcohol abuse or dependence during the initial visit; even less (34.4%) screened that many patients during an annual visit. Nearly all respondents (95%) reported “frequently” or “always” using quantity-frequency questions to screen for alcohol abuse, but only 35% “frequently” or “always” used the CAGE questionnaire. Only 20% of the respondents rated treatment resources as adequate for early problem drinkers, and 72% preferred not to counsel these patients themselves. A belief that a primary care physician could have a positive impact on an alcohol abuser was less likely to be held by respondents who were older, in a nonurban setting, or had more years in practice (P = .05).

CONCLUSIONS: A substantial proportion of the physicians in our survey sample were not following NIAAA recommendations. Most physicians preferred not to do the counseling of nondependent problem drinkers themselves, but to refer those patients to a nurse trained in behavioral interventions.

Although the prevalence of alcohol abuse and alcohol dependence in general medical clinics ranges from 10% to 20%,1,2 screening for problem drinking by primary care providers has been limited.3-6 Several barriers to widespread screening for alcohol use have been reported, including physician time constraints and reticence to ask patients potentially offensive questions.7,8 Physicians may also be confused about the numerous methods used to screen for alcohol abuse. These include questions about the quantity and frequency of alcohol use,9 CAGE (Cut down, Annoyed by criticism, Guilty about drinking, Eye-opener drinks) questions,10 the Michigan Alcoholism Screening Test (MAST),11 the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria,12 the Alcohol Use Disorder Identification Test (AUDIT),13 and laboratory markers.14 In 1995, the National Institute of Alcohol Abuse and Alcoholism (NIAAA) published recommendations on screening and management of alcohol abuse by primary care providers,9 but the impact of this document on clinical practice is unclear. Our goal was to determine if primary care physicians were following the NIAAA guidelines.

Methods

We mailed questionnaires to all 210 internists and family physicians in the Jefferson Health System in November 1997 to assess their alcohol screening behaviors and beliefs. The practices are widely distributed throughout the metropolitan Philadelphia area. We sent a second survey to nonrespondents after 6 weeks. All respondents were guaranteed confidentiality.

The questionnaire asked about the proportion of patients screened for alcohol abuse during the initial visit or an annual visit, as well as the proportion of patients believed to be alcohol dependent. The instrument also included questions about the types of screening methods used and reasons screening might not occur. For patients identified as alcohol dependent, physicians were asked about the availability and success of treatment interventions. Additionally, we asked if the respondent would prefer to counsel early problem drinkers personally or refer them to a nurse trained in behavioral counseling. We obtained practice and demographic information, including physician sex, specialty, affiliation with university or community hospital, and number of years in practice. Our study was approved by the Thomas Jefferson University Institutional Review Board.

We used Jonckheere-Terpstra tests to look for associations between ordered categorical variables. Chi-square tests were used to test for associations between nonordered categorical variables. We performed calculations using SAS 6.12 software (SAS Institute, Inc, Cary, NC).

Results

The survey response rate was 68% (N = 131). Seventy percent of the respondents were men; 39% were aged younger than 40 years, and 19% were older than 60 years; 53% practiced internal medicine, with the remaining 47% in family medicine. Respondents were divided evenly by setting (48% urban and 52% suburban), and 33% were affiliated with a university hospital. Nonrespondents were more likely (P <.05) to be men than women (82% vs 70%) or affiliated with community hospitals (81% vs 67% university affiliated). Only 64.9% of the respondents reported screening 80% to 100% of their patients for alcohol abuse or dependence during the initial visit); 34.4% of respondents said that they screened that many during an annual visit. One third of the respondents admitted to screening · 40% of patients during an annual visit. Eight percent of respondents responded that <1% of their patients were alcohol dependent; 80% estimated that this proportion was 1% to 10%; and 12% estimated that more than 10% of their patients were alcohol dependent.

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