Alcohol impairment is the single largest driving force behind traffic deaths in the U.S., but the problem may be taking a back seat to other issues during the office visit.
Charles O’Brien, MD, PhD, Kenneth Appel Professor and founding director of the Center for Studies of Addiction at the University of Pennsylvania Perelman School of Medicine in Philadelphia, said that less attention is paid to alcohol-impaired driving than to opioid addiction, diabetes, and coronary disease.
“But if you had to consider all the disruption and problems, alcohol is even [worse],” he said.
A report published this year by the National Academies of Sciences, Engineering, and Medicine aims to change that by outlining a sweeping public health approach to potential solutions. But despite the scope and severity of the problem, barriers to real progress remain substantial, according to experts.
A belief that a certain amount of drinking is normal may have curtailed screening for and treating alcohol use, said Richard Saitz, MD, MPH, FACP, chair of the department of community health sciences and professor of community health sciences and medicine at Boston University School of Public Health. But that thinking may risk overlooking binge drinkers, who are often responsible for crashes, according to the National Academies report.
The report, “Getting to Zero Alcohol-Impaired Driving Fatalities: A Comprehensive Approach to a Persistent Problem,” notes that 29 people die in the U.S. each day due to an alcohol-impaired driving crash. (The report is free to download online.) And a 2017 National Highway Traffic Safety Administration report found that in 2016, there were 10,497 fatalities in motor vehicle traffic crashes involving drivers with a blood alcohol content (BAC) of 0.08 g/dL or higher, or 28% of all traffic fatalities that year.
The National Academies report recommended increasing alcohol excise taxes, enhancing enforcement such as sobriety checkpoints and DUI courts, changing the limit for BAC set by state law for driving from 0.08 g/dL to 0.05 g/dL, and using engineering solutions such as ignition interlocks.
It made specific recommendations for ways that physicians could help, including by adopting an evidence-based approach known as SBIRT (screening, brief intervention, and referral to treatment) and by improving underuse of medications to treat alcohol addiction and decrease cravings.
However, the report also recommended that physicians get further involved by counseling patients against riding with impaired drivers, promoting local sobriety checkpoints, supporting mass-media campaigns against alcohol-impaired driving, and joining multicomponent interventions in coalitions of community group members.
That may sound like a lot to take on for primary care physicians who are already facing overwhelming time constraints. But busy physicians can tailor what they can do to the needs of their community, their resources, and their level of comfort with the issue, said Steven Teutsch, MD, MPH, FACP, co-editor of the report and coauthor of an accompanying editorial published on Jan. 17 by Annals of Internal Medicine. A good place to start is with screening, he noted.
“Alcohol screening needs to go from an occasional to a routine part of care,” said Dr. Teutsch, a senior fellow of the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California, Los Angeles (UCLA), and adjunct professor at UCLA's Fielding School of Public Health.
“There are a lot of services that don't add a lot of value, like [screening for prostate-specific antigen],” he said. “But here's one that clearly does.”
Asking the right questions
Talking to patients about alcohol use can help suss out those who may have a problem that could lead to driving while impaired. But it's an uphill battle for physicians, especially when addressing the subject with those who haven't suffered the consequences of their alcohol use, said Elisabeth Poorman, MD, a clinical instructor at Harvard Medical School in Boston.
For example, a patient recently told her that because she was still able to go to work and had no seizures, she felt it was okay to drink a bottle and a half of wine every night.
“There's a common preconception of what binge drinking and [alcohol use disorder] look like, [so] you're either an alcoholic or you're not,” she said. It's up to physicians to discuss the health effects of overdrinking even if the drinking is not yet affecting the patient's life negatively, she said.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) said asking just one question can accurately identify patients who meet its criteria for at-risk drinking or dependence: “On any single occasion during the past three months, have you had more than five drinks containing alcohol?”
But just asking “How much do you drink?” can yield misleading results, cautioned Federico E. Vaca, MD, MPH, professor of emergency medicine at the Yale School of Medicine in New Haven, Conn., a previous medical fellow at the National Highway Traffic Safety Administration, and the director of the Yale Developmental Neurocognitive Driving Simulation Research Center. Many people have a glass or two of wine after work nearly every day of the week, but it's unclear if they are small or large glasses unless you ask, he explained.
“If a patient says ‘I drink only twice a month,’ you have to ask the right questions to find out that those two times he goes out with friends and has six or seven beers in a night or five beers and a couple shots. Those are extreme binge drinking episodes and risks for injury and getting behind the wheel,” Dr. Vaca said.
Experts recommend using tools such as the 10-question Alcohol Use Disorders Identification Test (AUDIT) or the 4-question CAGE questionnaire to help determine if a patient is consuming more than healthy daily limits, which the NIAAA defines as 14 standard drinks per week or 4 drinks per day for men and 7 standard drinks per week or 3 drinks per day for women. A standard drink equals one 12-ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits.
Also, follow up by asking if the patient uses over-the-counter pain medications, tranquilizers, or medications for sleep, said Dr. O’Brien. “All of these increase the risk of automobile accidents,” he explained.
Internists who feel comfortable treating patients identified at risk for alcohol misuse or alcohol use disorders should follow up with those patients much more closely, Dr. Vaca recommended.
Dr. Poorman asks patients to try to completely abstain from alcohol consumption for 30 days. “It's a good way into the conversation. It's blunt, but people respond well,” she said.
Physicians also need to better understand medication uses, Dr. O’Brien said. For example, naltrexone can help with cravings, he noted. In addition, acamprosate and disulfiram and an extended-release injectable naltrexone are currently FDA-approved for treating alcohol dependence, according to the NIAAA.
Patients should know their numbers—drinks per day and week—just like they know their cholesterol numbers, Dr. Saitz said. He suggested asking these questions of patients who exceed currently recommended amounts: “Did you know that drinking those amounts puts you at risk for car crashes? That even one drink can contribute to that? Would you like to think about strategies to not have that happen?”
Have conversations in a nonjudgmental, empathic, nonthreatening way just as you would when talking about sexual risk behaviors or smoking, he said.
Physicians should refer to a specialized treatment program if they are not comfortable prescribing medications or if patients would be better handled by a psychologist, an addiction medicine specialist, and/or a treatment center, Dr. Vaca said.
Also refer patients who have been asked to cut back on their alcohol use but who subsequently fall, injure themselves, or have DUIs, and consider the long view for patients with alcohol use disorder, Dr. O’Brien said.
“The most wasteful way to address this is with expensive inpatient programs where [patients] feel great for a while but then relapse,” he said. “We have to get people to realize they have to change their lifestyle.”
Physicians need to get more training to work with at-risk patients, not just those who present with severe symptoms that they see during their training in the ED, said Dr. Poorman.
“It should be part of taking vitals. You ask about depression, anxiety, and alcohol use,” she said.
Dr. Saitz agreed. “Handle unhealthy alcohol use as a risk factor just like smoking … or diet,” he said.
Organizations like ACP can contribute to that effort through continuing education basis, said Dr. Teutsch. Physicians also are needed to advocate in their local communities and with their local health and accountable care organizations, he said.
That advocating should include ways to give physicians time to incorporate the report's recommendations, said Dr. Poorman.
“I feel like the guideline is well meaning and a good starting point, but until we deal with the completely unreasonable demands on primary care doctors it's going to fall on deaf ears,” she said. “We have to advocate for more face time with our patients.”
Dr. Vaca said it's time to consider what can be done given primary care's known effective and vital position on the front lines of the public's health. He talked about what he sees in the ED as a result of alcohol-related injuries and crashes—patients ejected out of vehicles or hit by another car, suffering serious and fatal head injuries and spine and pelvic fractures.
“We need to deeply consider what alcohol misuse and alcohol use disorders does and is currently doing to our patients and our communities,” he said.