Are We Making Alcohol Screening Too Complicated?
Gina Lasky, PhD, Health Management Associates Community Strategies (HMACS) Project Manager & Leigh Fischer, MPH, CPS II, Director of SBIRT Colorado, Peer Assistance Services, Inc.
April is alcohol awareness month and over the last year, HMACS has worked on a number of projects related to the implementation of universal alcohol screening and brief intervention in primary care and other general health settings. Our experience with our partners has left us asking big questions.
Efforts to increase universal screening and early intervention for alcohol use in physical health care settings are designed to provide a simple, easy, and flexible approach to identify and prevent potential alcohol-related health concerns. At least 38 million adults drink too much, and most do not have an alcohol use disorder (CDC, 2014). Drinking above moderate levels, and other drug misuse, contributes to cardiovascular disease, cancers, unintended pregnancy, sexually transmitted infections, depression, anxiety, suicide, injury, and violence. Yet only 1 in 6 people have ever talked with a health professional about alcohol as part of their healthcare.
Screening and brief intervention for alcohol misuse in primary care is recommended by the US Preventive Services Task Force and ranks as one of the most effective and cost-effective preventive interventions available to healthcare providers. The overarching goal of screening and brief intervention efforts is to normalize alcohol screening- similar to how screening for tobacco use, depression or breast cancer has become a standard of good care. The fundamental principles of screening and brief intervention include:
- Alcohol is a health issue and not simply a behavioral health issue. Addressing alcohol does not require expertise in behavioral health.
- Screening and brief intervention can be as basic and short as routine, universal screening using a validated, single-item screening question, followed by brief feedback and recommendations around cutting back or quitting for those who scored “positive” on the screening. Use of a comprehensive screening tool (Audit, CRAFFT, etc.) can further identify individuals who are at risk for alcohol problems and health challenges, and distinguish the need for a brief intervention or a treatment referral.
- Everyone can benefit from greater education about alcohol use, appropriate limits, and health risks.
Although identification of alcohol use disorders is important, universal screening is even more important to recognize potential risk and provide early intervention for moderate use—those of us who are using too much alcohol but may not be aware of it: the executive who has 3 drinks a night to “unwind”, the woman who regularly drinks 2 glasses of wine with dinner, or the sports fan who has 5 beers watching the game. Alcohol use is part of our culture and many of us do not consider regular use of alcohol as a risk factor for health problems. As a society, do we know what constitutes moderate to significant alcohol use? How much is okay? Have our primary care providers asked us about our alcohol use and provided information about these health risks in the same way that they would if we were smoking, eating too much fat, or ignoring a chronic disease?
Alcohol is the 4th leading cause of preventable death and the U.S. spends nearly $224 billion a year on costs attributed to excessive alcohol consumption; alcohol needs to be a part of our health discussion.
If alcohol use can change our health and impact longevity, then why has the uptake of screening and brief intervention been so slow? This simple approach has national policy support, funding to support training and technical assistance programs, and reimbursement for providers, yet in our work we find that implementation of the process continues to face considerable barriers.
All of this has made HMACS and our partners with the SBIRT Colorado program at Peer Assistance Services, Inc. ask a different question to take us one step further: Is the reason why the uptake of screening and brief intervention been so slow because it is asking us to confront a contradiction?
The information in our day to day lives tells us that alcohol is not only okay but enjoyable and important. In our broader culture, alcohol is present at all major life celebrations, professional events and parties, social engagements with friends, sporting events, live music and concerts, restaurants, and in our homes. For many of us, going out for a nice dinner and having a glass of wine, or having a beer with friends, is a quality of life factor.
For these reasons, it is not easy or comfortable for our health care system and providers to address alcohol. Alcohol use is not a black and white issue like tobacco use. Additionally, providers could easily feel screening is an intrusion into our personal lives and a judgment on our quality of life. It is also asking providers to influence and shape our culture. No surprise this is encountering some resistance and barriers.
Perhaps what we need then is a more honest conversation about the role of alcohol in our lives-both positively and negatively and how we as a society want to strike a balance. Alcohol use is a continuum—much like the amount of fat, sugar, and salt that we eat or the amount that we exercise, or the degree of emotional wellness we experience from time to time.
Should alcohol screening be different from other essential health screenings like tobacco, depression, body mass index and obesity? We think not.
We welcome your thoughts and impressions and hope to have a conversation. Visit the HMACS blog.