Original Research

Screening for Alcoholism in the Primary Care Setting

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References

Other preventive services

We also assessed the rate of talks about healthy eating as a comparison for the alcohol discussions. A total of 44.6% of patients reported having a conversation about healthy eating compared with 16.1% having an alcohol discussion. On the chance that people who drank excessively might differentially remember conversations with their physicians, we assessed the association between alcohol use and reports of experiencing counseling on healthy eating. No significant associations were found between reported conversations about eating and any variable related to alcohol consumption even after controlling for sex, age, sex-by-age interaction, race, income, and education. Similar results were obtained for discussions about exercise, AIDS, and illegal drugs. Discussions about illegal drug use occurred less frequently than discussions about alcohol use (12.5%). Discussions about AIDS were reported by 26.1% of the respondents, exercise-related conversations were reported 47.4% of the time, and smoking was mentioned by 49.2% of the respondents. Considering any preventive health discussions (smoking, drinking, drug abuse, exercise, healthy eating, or AIDS), 97.4% of the respondents reported a discussion of at least 1 topic.

Discussion

Physicians currently incorporate preventive counseling about behavioral health risks as part of standard clinical care. In a recent survey of general practitioners, 97% of those surveyed thought that members of their profession should inquire about drinking behaviors.15 Moreover, brief office visit screening followed by physician advice has been documented as effective in reducing alcohol consumption.16,17 Despite the general positive opinion of alcohol screening, however, discussions about AIDS and other health-related behaviors were discussed much more frequently than alcohol-related behaviors.

Our analysis identified patients who consume a significant amount of alcohol, yet did not report being screened or counseled by their physicians. We gathered information about the magnitude of use, as well as about the presence or absence of a discussion regarding alcohol. This allowed us to examine 2 important aspects of alcohol screening: (1) the demographic features that predicted it, and (2) whether these demographic features represented patients who actually consumed large amounts of alcohol and could therefore benefit from counseling.

Although the BRFSS did not assess alcohol dependence or abuse directly, the goal of the study was to designate which patients might be appropriate candidates for screening or preventive counseling. Assessments of alcohol abuse or dependence using strict Diagnostic and Statistical Manual of Mental Disorders – 4th Edition (DSM-IV) criteria require insight, as well as a willingness to share this information with the interviewer. Kosten and Rounsaville18 found that DSM-based diagnostic interviews for alcoholism and substance abuse showed the lowest sensitivity relative to other psychiatric diagnoses. Therefore, more recent surveys of alcohol abuse assess the quantity of consumption before applying strict DSM-IV criteria.19,20 Although participants may also minimize actual consumption, the screening for quantity requires less insight than a formal diagnosis and may more effectively identify candidates for counseling. However, our findings suggest that physicians do not routinely attempt to ascertain alcohol use quantitatively.21,22 Implementing alcohol screening as a routine preventive health care practice would allow physicians to detect problems without relying on insightful spontaneous reporting from patients.

The most successful strategy to identify more candidates for treatment involves simply screening a larger number of patients, especially high-risk patients. Our data suggest that physicians do target discussions somewhat toward people who report excessive alcohol consumption. Approximately 16% of the general patient population reported such a discussion, but this rate was greater (27.8%) among heavy or binge drinkers. Unfortunately, these data also suggest that the majority of patients who might benefit from such counseling, did not report a discussion about alcohol use. Individuals who are likely to be appropriate candidates but who were not counseled include white patients and women (widows, in particular).

The frequency of discussions about alcohol for women and widows who drank excessively was low. This finding is consistent with current research demonstrating that alcohol problems among women, and widowed women in particular, are under-recognized. Physiologically, the lower body water volume in women, especially in elderly women, increases the detrimental effects of alcohol.23 Physicians also appear to have more difficulty recognizing alcohol problems among the elderly.24 Alcohol-related symptoms among elderly women may be misinterpreted as caused by depression, anxiety, or other psychiatric problems.25 Elderly women taking psychoactive medications or medications with sedative effects may be even more difficult to assess. Moreover, our analysis categorized excessive drinking using a single criterion for all respondents. Evidence is mounting that indicates that women26 and the elderly23 are more at risk from lower levels of drinking. Had we lowered our criterion for these patients, the magnitude of problem drinking would have appeared even greater.

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