Diabetes and alcohol use: Detecting at-risk drinking
Asking a simple question helps uncover at-risk drinking in patients with diabetes, and brief office interventions have proven effective in modifying behavior.
Assessing alcohol use: Obstacles and solutions
Although alcohol use can be readily evaluated during routine primary care appointments, it is often neglected, perhaps due to a lack of awareness about its impact on diabetes.15 Those who are most often assessed tend to have a psychiatric diagnosis or other condition raising a red flag for physicians.28 When internists, general practitioners, and psychiatrists were questioned in a study regarding patients’ alcohol and drug use, all 3 groups were misinformed about which substance-use treatments were empirically supported29 and did not believe that treatment for alcohol abuse held much promise. Another study showed that physicians can be reluctant to screen for alcohol use because of the difficulty in recognizing a problem, the perceived unimportance of alcohol use as a health risk, a supposed lack of adequate intervention tools, and a fear of stigmatizing patients.30 Physicians are more likely to discuss alcohol use under certain extreme conditions such as when a patient smells of alcohol.
Multiple opportunities to ask in the VA system. In the Veterans Health Administration, primary care VA providers have reported that prompts for alcohol screening embedded in computerized progress notes, clinical reminder lists, and annual health evaluation forms encourage them to assess alcohol use. Other useful materials include manual checklists and reference cards.31 These providers also report that education, feedback on rates of alcohol screening, and increased supervision facilitate assessment. Finally, providers indicate that asking nurses or clerical staff to administer the screen improves completion rates.
Ask a simple question
“How often have you had a drink containing alcohol in the last year?” or “How many drinks containing alcohol did you have on a typical day when you were drinking in the last year?” are questions that can help you compare a patient’s alcohol use to the at-risk drinking cutoffs established by the NIAAA.1,2
Recent research has also validated the use of a single question in identifying NIAAA-defined at-risk drinking.32 Simply ask patients, “How many times in the past year have you had X or more drinks in a day?” (X=5 for men or 4 for women). The screen is positive when a patient acknowledges having done so at least once in the past year. This question was 81.8% sensitive and 79.3% specific for unhealthy alcohol use, and 87.9% sensitive and 66.8% specific for current alcohol abuse or dependence.32 Advantages of this method are its brevity, ease of scoring, validity in the primary care setting,32 and ease of recollection for treatment providers (TABLE 1).1,2
TABLE 1
Ask these simple questions to assess alcohol use1,2
| To assess… | Ask… |
|---|---|
| Frequency of alcohol use | “How often do you drink alcohol (including beer or wine)?” or “How often have you had a drink containing alcohol in the last year?” |
| Quantity of alcohol use | “When you do drink alcohol, how many standard* drinks do you have?” or “How many drinks containing alcohol did you have on a typical day when you were drinking in the last year?” |
| Binge drinking | For men: “How often do you have 5 or more standard* drinks on one occasion?” For women: “How often do you have 4 or more standard* drinks on one occasion?” |
| Alcohol use with the NIAAA single-question screen | “How many times in the past year have you had X or more drinks in a day?” (X = 5 for men and X = 4 for women; positive response ≥1) |
| *A standard drink is equal to 12 oz. of regular beer, 8 to 9 oz. of malt liquor, 5 oz. of wine, or 1.5 oz. of 80-proof spirits.1 NIAAA, National Institute on Alcohol Abuse and Alcoholism. | |
Brief intervention works in primary care
Brief interventions for drinking have strong empirical support. In a review of treatments for alcohol abuse and dependence,33 brief intervention was one of only 2 “efficacious” treatments.
Although some individual studies of brief alcohol interventions in primary care have not shown favorable results, several systematic reviews have demonstrated the efficacy of such interventions in this setting. General practitioner–delivered brief interventions led to significantly better patient outcomes compared with standard care, and “very brief advice” resulted in reductions in alcohol consumption overall and in the percentage of “excessive drinkers.”34 In a review of health behavior interventions,35 brief interventions reduced risky or harmful drinking. In one of 2 meta-analyses that support this finding, brief interventions with primary care patients not seeking treatment for alcohol abuse yielded small-to-medium effect sizes relative to control conditions.36 In the other study, brief interventions significantly reduced longer term alcohol use in primary care patients.37
The US Preventive Services Task Force conducted a systematic review of behavioral counseling interventions and recommends screening and brief interventions for unhealthy drinking in primary care.38,39 Its findings indicate that alcohol use declines significantly after brief interventions containing at least 2 of the following elements: feedback regarding drinking, advice to reduce drinking, or goal setting.
