Alcohol use, misuse recently on the rise
With routine use of a short screening tool, primary care physicians could more frequently flag emerging alcohol issues.
More U.S. adults have engaged in risky or hazardous drinking in recent years, a spate of studies show, but screening and intervention efforts have fallen short in addressing these unhealthy habits.
Nearly 90,000 deaths each year among adults ages 20 to 64 years can be attributed to excessive alcohol consumption, according to a recently published study, which was based on data from 2015 to 2019 and incorporated 58 alcohol-linked causes of death. Those alcohol-linked deaths comprise one out of every eight deaths overall in that age group and one out of every five deaths in adults ages 20 to 49 years, according to the findings, published Nov. 1, 2022, by JAMA Network Open. “We do actually think that these could be conservative estimates,” said Marissa Esser, PhD, MPH, the study's lead author, noting that the analysis predates the COVID-19 pandemic.
Excessive alcohol consumption appears only to have worsened since March 2020. Alcohol-related deaths (including deaths from alcohol use disorder, or AUD) increased 25.5% between 2019 and 2020, according to another study, published May 3, 2022, in JAMA.
Various pandemic factors have been cited as potential contributors, including financial and other stressors, increased isolation, and the lack of healthier outlets, such as gyms. It didn't help that policy changes in recent years have loosened access to alcohol in some states, such as expanding online purchases and delivery to residential homes, said Dr. Esser, who is also lead of the CDC's Alcohol Program.
“There has been a general trend toward deregulation,” she said. “People are having more options for how to obtain their alcohol.”
Meanwhile, other research indicates that physicians could assume a more prominent role in asking about alcohol use and following through with brief counseling if they identify worrisome patterns. One recent analysis of the National Ambulatory Medical Care Survey, based on data from 2014 to 2016, found that screening occurred in just 2.6% of primary care visits, which meant that about 13% of patients would be screened over the course of a year, according to the findings, published in November 2022 in the Journal of General Internal Medicine (JGIM).
With routine use of a short screening tool, primary care physicians could more frequently flag emerging alcohol issues, said Jeanette Tetrault, MD, FACP, a professor of medicine and public health and fellowship director for addiction medicine at Yale School of Medicine in New Haven, Conn.
“I think one of the real benefits of primary care is you have lots of touch points with your patients and you can look for trends,” Dr. Tetrault said. “So if you screen them at their physical in January and their screening question is negative, and then you screen them in June when they come in after a fall and their screening test is positive, that delta is really important information.”
Low screening rates
ACP Member Brittany Chatterton, MD, MAS, the JGIM study's lead author, said she decided to study screening after diagnosing some patients in her practice with AUD and wondering why their drinking hadn't been identified sooner. “Where did we miss them?” asked Dr. Chatterton, a general internal medicine physician at the University of California, Davis, Medical Center. “So how are we doing with our actual screening to be able to catch these patients earlier in their trajectory?”
The JGIM study identified the 2.6% screening rate per primary care visit based on screenings that were documented in the medical record. Alcohol counseling, provided either by a physician or through a referral, was noted in 0.8% of office visits. Another recent study found higher screening rates. Among 876 primary care physicians, 52.2% reported screening during the annual physical, and 15.7% said they screened at every visit, according to the findings, published in February 2022 in the American Journal of Preventive Medicine.
One potential explanation for the difference in findings is that the American Journal of Preventive Medicine study was based on physician self-reporting, Dr. Chatterton said.
“I think it's easy to overestimate at times your personal screening,” she said. “Especially if you were maybe doing it more frequently around the time of when the survey was taken, you can have a recency bias.”
The U.S. Preventive Services Task Force recommended in 2018 that adults should be screened in primary care settings for unhealthy alcohol use. The Task Force, which highlights one- to three-question screening tools such as the Single Alcohol Screening Question (SASQ) and the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C), recommends brief behavioral counseling when risky or hazardous drinking patterns are identified.
Dr. Chatterton screens all her new patients, as well as existing patients at least once a year, “just to make sure that we're checking in and things haven't been changing over the course of time that I've been seeing them,” she said. She typically uses the AUDIT-C questionnaire and alerts her patients that it's a routine practice.
“I always preface it with telling my patients that if they can answer me honestly, it's going to help me best take care of them,” she said.
For time-pressed physicians, even a single-item screening question such as the SASQ may identify at-risk patients, Dr. Tetrault said. Along with screening during the annual physical, physicians may consider doing so again if there's a change in the patient's health, such as newly elevated blood pressure or stomach pain, she said.
The alcohol screening question can be asked along with other questions that involve sensitive subjects, such as other substance use or sexual activity, Dr. Tetrault said. But it's important to ask the question as it was written and validated, she cautioned.
“I have seen people editorialize questions,” she said. “‘You don't drink more than five drinks, do you?’ It comes with a negative connotation.”
When patients screen positive, defined as reporting consuming five or more drinks on occasion for men or four or more drinks on occasion for women or individuals older than age 65 years, Dr. Tetrault asks them to elaborate a bit on the circumstances. “I say, ‘Tell me more about that.’ I come at it from a very open-ended frame.”
One patient might describe consuming a 12-pack of beer every weekend, while another might report overindulging at a recent wedding, with no plans to repeat that practice, she said. Sometimes it can be challenging to discuss health risks with a patient who doesn't meet AUD criteria but whose drinking habits place them in the at-risk category, Dr. Tetrault noted.
“It's this group of folks that could potentially have complications but may not be experiencing them currently,” she said. “I also meet resistance sometimes on the part of patients who say, ‘I don't drink as much as my friends.’” Or patients will say that they don't have a problem because they don't drink and drive, or they are successful on the job, she said. “They don't necessarily see the potential implications of their alcohol use.”
If unhealthy drinking patterns are identified, brief counseling interventions over time might spur change, Dr. Tetrault said. She cited several studies, including a Cochrane Review meta-analysis, which found that five or fewer counseling sessions in the primary care setting could exert a meaningful impact. By a year later, the adults who had been counseled were able to reduce their weekly alcohol consumption by 20 g compared with control groups, according to the findings, published in July 2019 by Alcohol and Alcoholism.
The goal is to tap into each patient's motivation to cut back, whether that is to improve relationships with loved ones, reduce spending on alcohol, or promote better sleep, Dr. Tetrault said. “If the provider is implementing their own agenda on why they think the patient should cut back, you meet resistance there,” she said.
Given that some patients won't quit drinking, any reduction in alcohol is preferable to none, Dr. Chatterton said. One strategy she uses is to ask the patient to consider which situations spur excessive drinking, and then help them brainstorm ways to avoid those situations, such as a sporting event, or to limit their consumption when they do attend.
Some heavy drinkers may not realize how much they are consuming, Dr. Chatterton said. Along with asking them to document their drinking, she often suggests that they take notes on where they were and their feelings at that point. Were they alone or in a large social setting? Did they feel nervous or anxious or some other emotion?
From there the patient can set goals to cut back, with follow-up visits to discuss where they are, Dr. Chatterton said. “That gives them some accountability,” she said.
For treating AUD, physicians also should more frequently consider medications, such as naltrexone, topiramate, acamprosate, or gabapentin, said Triveni DeFries, MD, MPH, a general internal medicine physician and addiction medicine specialist at the University of California, San Francisco (UCSF). “They are massively underprescribed,” she said.
Dr. DeFries cited a study, published in August 2021 in JAMA Psychiatry, which assessed data from the 2019 National Survey on Drug Use and Health. Among the 14.1 million adults with alcohol use disorder, 7.3% reported getting any related treatment in the prior year, and 1.6% reported taking evidence-based medications, according to the findings.
“There is this enormous treatment gap when it comes to alcohol use disorder that primary care physicians can address,” said Dr. DeFries, who is also an assistant professor of internal medicine at UCSF.
The medications also can be prescribed to patients with AUD who aren't ready to quit to help them drink less, and physicians don't need any special training, Dr. DeFries said.
“Physicians can counsel patients and support patients about cutting back, knowing that that's also good for their health,” Dr. DeFries said. “It changes the way that maybe traditionally physicians have been taught, that a patient has to abstain and if they don't, then they've failed, or we've failed. Which really isn't true.”
As SARS-CoV-2 becomes more endemic, the excessive drinking patterns among U.S. adults don't appear to have abated, according to data published May 4, 2022, by JAMA Network Open. The analysis, which used predictive modeling, found that AUD-related deaths were nearly 25% above projections in 2020 and nearly as high in 2021. Also, the largest increase in AUD mortality (40.47% in 2020 and 33.95% in 2021) was seen in the youngest age group, those 25 to 44 years of age.
A subsequent analysis, which extends into early 2022 and has been submitted for publication, finds a similar elevated pattern, said ACP Resident/Fellow Member and coauthor Yee Hui Yeo, MD, MSc, a gastroenterology and hepatology fellow at Cedars-Sinai Medical Center in Los Angeles. “It shows as of now no significant decrease in the trend in alcohol use-related deaths,” Dr. Yeo said.
While physicians might feel daunted about delving into the sometimes sensitive subject of alcohol, a more proactive approach could help forestall hypertension and other health issues that might crop up later, Dr. Tetrault said. Keep questions open-ended and encourage the patient to drive the conversation and set their own goals, she said.
“From a primary care provider's standpoint, in the universe of time that you have with your patients over weeks to months to years, this can save you a lot of time,” she said. “You're really trying to prevent downstream consequences by catching something early.”