Height? Weight? Any changes in your health? Do you smoke? Simple screening in the doctor's office can help clinicians pick up on potential health problems. But these perfunctory questions--combined with any other follow-up an individual doctor might decide to do--fail to detect one exceedingly common health issue: too much drinking.
Each year more than one in 12 Americans will have a clinically diagnosable drinking disorder, and many heavy drinkers fail to be treated--or even identified. According to a new report, doctors miss nearly three quarters of their patients who have an alcohol problem.
"In clinical practice, detection of alcohol problems often relies of clinicians' suspicion," wrote the authors of the new paper, published online January 14 in Annals of Family Medicine. That informal assessment is falling short, according to their findings. "Clinician suspicion of alcohol problems missed the most patients with a potential problem," they reported.
If clinicians could more effectively screen for alcohol abuse, they could provide or recommend treatment and help patients cut back on their drinking. Reducing alcohol use could improve individuals' health, increase the safety of others as well as reduce the estimated $223 billion (in health care and other expenses) that such overindulgence costs the U.S. each year.
For the study, researchers, led by Daniel Vinson, of the Department of Family and Community Medicine at the University of Missouri, surveyed 94 primary care doctors in several states and 1,699 of their patients. Consenting patients completed a written anonymous survey after meeting with their doctor. Similarly, doctors responded to a survey about each of the patients.
The responding patients answered five questions pertaining to alcohol use, aimed at judging whether the individual engaged in hazardous or harmful alcohol consumption. Three of these vetted questions were part of the Alcohol Use Disorders Identification Test, and two of them were from the Diagnostic and Statistical Manual of Mental Disorders. The questions included:
- In the past 12 months how often have you had a drink containing alcohol?
- How many drinks containing alcohol have you had on a typical day when you are drinking?
- How often have you had six or more drinks on one occasion?
- In the past 12 months, how often have you had a lot more to drink than you intended to have?
- In the past 12 months, how often have you been under the influence of alcohol in situations where you could have caused an accident or gotten hurt?
For the first three questions, respondents answered on a scale of zero to four (with zero being no drinking and four being frequent and heavy alcohol consumption). Those individuals scoring eight points or more are considered to engage in alcohol use on hazardous levels. For the last two questions, if people report those things happen monthly or more often, they are considered to have harmful drinking. (As an example, a "hazardous" male drinker would report having more than four drinks on one occasion or more than 14 drinks in a week; a moderate male drinker would have fewer than five drinks on a single occasion and fewer than 15 drinks in a week. The number of drinks is lower for women.)
Doctors were asked to report whether the patient has an alcohol problem by responding: no, yes (hazardous drinking), yes (alcohol abuse/dependence) don't know or that the patient is a former drinker/recovering alcoholic.
Most of the patients that clinicians suspected to have alcohol problems did screen positive for it on the questionnaire. And the doctors report having talked about alcohol use with these patients either on that or a previous visit in most (85 percent) cases.
But the doctors picked up on only about 27 percent of patients who screened positive for such issues on the questionnaire. Although the doctors flagged fewer than 5 percent of patients as having some sort of alcohol problem, in fact, more than 10 percent of them actually did. (Roughly 50 percent reported being moderate drinkers and about 40 percent did not drink. Self-reported alcohol might be subject to the bias of underreporting, but these sorts of anonymous surveys should help improve accuracy by reducing the amount of stigma people might be sensitive to in reporting their use.)
Although the U.S. Preventive Services Task Force recommends screening, many doctors have reported that they skip alcohol-related questions because it takes extra time and because it seems distracting to the original purpose of a patient's visit. "These challenges will need to be addressed," the researchers noted in their paper.
Although doctors' time with patients it limited, the questionnaire for alcohol use used in the study was a brief five questions and could be completed before the primary clinician sees the patient. And the researchers recommend even using a simple question, such as "How many times in the pas year have you had X or more drinks in a day?" (Five for men and four for women would signify an instance of excessive use, for example.)
"Screening can be accomplished by asking only one or fewer questions," the researchers noted. "And subsequent brief interventions for problem drinking by primary care clinicians can significantly reduce hospital days and health care costs and mortality."
Identifying more patients in need of help could go a long way in improving health and reducing related costs over the long term. One study found that even simple help from a primary care doctor helped 40 percent of hazardous drinkers cut their alcohol consumption to safe levels. And in another study, of people 18 to 49 who consumed unsafe amounts of alcohol each day or week, only 7 percent of them reported that their doctor had asked them to reduce their drinking, and only 14 percent recalled being told about safe drinking amounts.
For those who could use help starting the conversation about drinking, the researchers also point to free online training from the University of Missouri that clinicians can consult for tips on how to talk with patients about drinking problems.