With all of the pressures on primary-care clinicians to see more patients while improving the quality of care, we need help in prioritizing the preventive services we provide. Responding to this need, the U.S. Preventive Services Task Force (USPSTF) has identified the most effective preventive measures, and a careful review has prioritized them based on how they fulfill two important criteria: burden of disease prevented when each service is delivered regularly and the cost-effectiveness of doing so (Am J Prev Med. 2006;31:52-61). This prevention priorities review of 25 USPSTF-recommended services found that only five were actually cost-effective for adults: aspirin prophylaxisfor cardiovascular risk, pneumococcal immunization and vision screening for those older than 64, and tobacco-use and alcohol-misuse screening and brief counseling.
Many clinicians may be surprised to see the alcohol-misuse listing. Providers tend to view their intervention as ineffectual —I know I did. That attitude may be the cause of a troubling finding from a recent national survey of problem drinkers: only 9% of them reported receiving any counseling from a clinician in the preceding year.
Our recently published article from the prevention priorities study focused on 10 trials of screening and brief advice for problem drinking in primary-care clinics (Am J Prev Med. 2008;34: 143-152). We found that problem drinkers in the intervention group were more than twice as likely as those in the control group to have overcome alcohol misuse within six months. Although these studies tested only physician advice and follow-up (usually by a nurse), there is no reason to believe that advice from nurse practitioners or physician assistants would be any less effective overall.
I hope you will be heartened by this finding and will implement a system to achieve similar results, since if your practice is like others, a significant proportion of your patients may be problem drinkers.
An effective system should include three components: screening, advice, and follow-up.
1. Screening. There are several good questionnaires to assess drinking behavior—CAGE, SMAST, and AUDIT among them. However, the clinician can do a good, brief screen by asking just two questions:
a) How many drinks have you had in the last week?
b) What are the most drinks you have had at one time in the last month?
If the response to the first question is at least 14 drinks (for males) or 11 (for females), or the response to the second question is four or more drinks, you should use one of the questionnaires to obtain more information.
2. Advice. Provide clear advice about the health consequences of drinking. If the patient is ready to reduce his or her alcohol intake, try to get a specific commitment about the planned reduction and provide a pamphlet on how the patient can achieve the goal. If the longer questionnaire suggests a serious drinking problem, you should also provide the patient with a referral to a formal treatment program.
3. Follow-up. Tell the patient you would like to call in a few weeks to see how it is going. This emphasizes your belief that alcohol misuse is an important problem and that you want to help the patient overcome it.
For more on this topic, see “Successfully treating problem drinking”.