From the Journals

USPSTF advises primary care to screen for unhealthy alcohol use

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Patients lack clear plans to cut back

The USPSTF recommendations to screen adults for unhealthy alcohol use acknowledge the serious public health problem it presents, wrote E. Jennifer Edelman, MD, and Jeanette M. Tetrault, MD, in an accompanying editorial.

The recommendations are similar to those issued in 2013 that endorsed screening and brief behavioral interventions for patients with at-risk alcohol use, they said. “Notably, the 2018 recommendations replace alcohol misuse with unhealthy alcohol use and explicitly recommend screening in all pregnant women,” they said.

In clinical practice, most patients with alcohol problems are seen for issues that are consequences of unhealthy alcohol use, such as poorly controlled hypertension, rather than the alcohol use itself, they noted. “Although patients are treated for their immediate problem, they often leave without clear plans to cut back or abstain from alcohol use and thus improve their health.”

Although the recommendations are based on studies showing the effectiveness of brief intervention in primary care, the interventions’ components tend not to be standardized in terms of content, delivery, dose, or duration, the editorialists noted. The terminology used in studies and in clinical practice is inconsistent as well and can cause confusion for doctors and stigma for patients, Dr. Edelman and Dr. Tetrault said.

In addition, they noted that the new USPSTF recommendations don’t incorporate guidance against any alcohol use while taking medications that may interact with it, such as sedating drugs and medications for opioid use disorders.

“Nonetheless, primary care physicians should focus on prevention of alcohol-related harms across the spectrum of alcohol use, including prescribing medications for alcohol use disorder when appropriate,” they noted. “Medications such as naltrexone, acamprosate, and disulfiram can easily be prescribed in primary care and do not require specific training” (JAMA. 2018 Nov 13. doi: 10.1001/jamainternmed.2018.6125).

Dr. Edelman and Dr. Tetrault are affiliated with Yale School of Medicine in New Haven, Conn. They had no financial conflicts to disclose.



All adults aged 18 years and older, including pregnant women, should be screened in primary care settings for unhealthy alcohol use and offered behavioral counseling if needed, according to recommendations from the U.S. Preventive Services Task Force.

Silhouette of a woman holding a bottle to her forehead. Vonschonertagen/Thinkstock

Adults who meet the criteria for unhealthy alcohol use should be offered brief behavioral counseling interventions, the task force concluded with a B recommendation.

However, the task force also concluded that evidence is insufficient to recommend screening for alcohol use in adolescents aged 12-17 years in primary care settings (an I statement), wrote Susan J. Curry, PhD, of the University of Iowa, Iowa City, and colleagues. The recommendations were published in JAMA as an update of the USPSTF 2013 recommendation on screening for unhealthy alcohol use in primary care settings.

Approximately 88,000 deaths occurred each year in the United States between 2006 and 2010, the task force noted. Those deaths include death by acute causes, such as alcohol-related injuries, and chronic causes, such as alcoholic liver disease. In addition, alcohol use during pregnancy is a major preventable cause of birth defects and developmental disabilities, the task force wrote.

After reviewing the evidence, the USPSTF concluded that brief behavioral counseling offered moderate net benefits for adults 18 years and older, including pregnant women, who met criteria for unhealthy alcohol use.

Unhealthy alcohol used was defined as exceeding the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommended limits of 4 drinks per day, or 14 drinks per week, for men aged 21-64 years, and 3 drinks per day, or 7 drinks per week, for women aged 21-64 years.

In the evidence review accompanying the recommendations, Elizabeth A. O’Connor, PhD, of Kaiser Permanente in Portland, Ore., and colleagues analyzed data from 113 studies, including 314,466 individuals; 10 studies included adolescents.

In 68 studies including 36,528 individuals, brief counseling was associated with fewer drinks per week, fewer individuals exceeding recommended limits for alcohol consumption, fewer drinkers reporting a heavy drinking episode, and a greater proportion of pregnant women reporting alcohol abstinence after 6-12 months.

None of the studies assessed benefits or harms, but no evidence suggested that the interventions could be harmful.

The USPSTF is supported by the Agency for Healthcare Research and Quality. The researchers had no financial conflicts to disclose.

SOURCES: Curry S et al. JAMA. 2018;320(18):1899-1909; O’Connor E et al. JAMA. 2018;320(18):1910-28.

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