Screening and Brief Intervention: USPSTF Update Affirms Recommendations and Highlights Evidence Gaps

The U.S. Preventive Services Task Force (USPSTF) has again made recommendations—to update those previously issued in 1996 and 2004—regarding screening and behavioral counseling for unhealthy alcohol use in primary care settings. These new recommendations are essentially unchanged from those of 2004.

• The Task Force recommends that clinicians screen adults and provide persons engaged in risky or hazardous drinking (defined as drinking that results in an increased risk for health consequences) with brief behavioral counseling interventions.
• The Task Force also concludes that the current evidence is insufficient to screen adolescents.

The recommendation to screen adults is “grade B,” meaning that there is high certainty that the net benefit is moderate. To screen, the USPSTF prefers validated single-item screens, the Alcohol Use Disorders Identification Test (AUDIT), and the first 3 items of the AUDIT (AUDIT-C). A positive screening test should be followed by a brief counseling intervention (at least 6–15 minutes), which is most likely to have efficacy if it is multi-contact. There is little evidence for efficacy of very brief single interventions.

Comments:

The evidence and recommendations are clear though very circumscribed: for adults in primary care with hazardous but not harmful or dependent alcohol use, screening and brief—but not too brief—multi-contact counseling can reduce consumption. The USPSTF also highlighted the unknowns:

• Impact on morbidity, mortality, and quality of life.
• Efficacy for people with alcohol use disorders (“Limited evidence suggests that brief behavioral counseling interventions are generally ineffective as singular treatments for alcohol abuse or dependence,” an observation that leaves clinicians in a quandary when they identify such persons by screening).
• Efficacy for adolescents.

Unfortunately, the USPSTF missed an opportunity to correct its prior poor choice to use the term “misuse.” Those with alcohol dependence may take issue with this term. For clinicians, the fact that “misuse” is sometimes used to refer to risky use and at other times used to refer to dependence (i.e., “severe misuse,” according to the U.S. Veterans Health Administration) is confusing at best. Little is new in this USPSTF statement, but it does again recommend a practice that should be widely disseminated.

Richard Saitz, MD, MPH

Reference:

Moyer VA on behalf of the U.S. Preventive Services Task Force. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. May 14, 2013 [Epub ahead of print]. doi:10.7326/0003-4819-159-3-201308060-00652.