Screening for Unhealthy Alcohol Use: Some Patients Don’t Want Their Clinician to Know

Routine screening for unhealthy alcohol use is recommended in primary care settings, but the utility of annual repeat screening is uncertain. This study included 18,493 Veterans Administration outpatients who had 1 to 4 prior negative annual in-person AUDIT-C clinical screens and completed both a clinical AUDIT-C screen and an AUDIT-C screen on a confidential mailed survey (that was not shared with the clinician) the following year. Test characteristics of the clinical screen were compared with the mailed survey response.

• Ten percent of those with a prior negative clinical screen reported unhealthy alcohol use on the mailed survey.
• Among those with unhealthy drinking on the mailed screen, agreement of the clinical screen dropped from 41% among those with only 1 prior negative screen, to 33% among those with 2, 26% among those with 3, and 17% among those with 4 prior negative clinical screens.
• Among those without unhealthy drinking on the mailed screen, agreement was consistently high (98%).

Comments:

Many of us have seen patients who repeatedly deny unhealthy alcohol use despite evidence to the contrary. This study found that having clinicians repeat the same questions at annual visits did not change these patients’ responses. Although the authors focus on the diminishing sensitivity of the AUDIT-C as an annual in-person screen, the responses to the AUDIT-C on the mailed survey suggest that many of these patients have insight about their drinking behavior and are more likely to respond truthfully by mail knowing that information is not shared with their clinician. The reasons these patients withhold truthful responses from their clinicians merits further investigation, because even if we develop alternative ways to detect their unhealthy alcohol use it will be difficult to address their problem in the absence of trust in their providers.

Peter D. Friedmann, MD, MPH

Reference:

Lapham GT, Rubinsky AD, Williams EC, et al. Decreasing sensitivity of clinical alcohol screening with the AUDIT-C after repeated negative screens in VA clinics. Drug Alcohol Depend. 2014;142:209–215.