Alcohol screening and intervention for risky drinking: A guide for physicians

A new review in CMAJ (Canadian Medical Association Journal) provides tips for physicians to help patients cut down on excessive alcohol use and is aimed at health care providers who are not addiction specialists. The article is based on current evidence, including recent Canadian guidelines.

"A broad range of health care providers without specific addiction expertise are well-positioned to identify individuals who drink at levels that are harmful before such patients have even considered changing their alcohol consumption or seeking treatment," writes Dr. Anne Moyer, Stony Brook University, Stony Brook, New York, with coauthor, Dr. John W. Finney, Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California. "Patients are likely to be receptive to a professional with whom they may already have a clinical relationship and whom they trust."

Current Canadian guidelines for low-risk drinking recommend no more than 10 drinks a week for women (with no more than 2 drinks a day on most days) and a maximum of 15 drinks a week for men (with no more than 3 drinks a day on most days). They recommend that pregnant women abstain from drinking.

An estimated 15%-20% of Canadians drink more than that in the recommended guidelines. Harms from at-risk drinking and alcohol misuse are responsible for substantial disability and 7.1% of all deaths in Canada.

To help curb the growing abuse of alcohol and its harms, action is needed at both the population level, such as alcohol regulation and pricing, and the individual level through education and intervention.

Health care practitioners should first screen, asking patients if they consume alcohol and if so, how many days a week do they drink and how many drinks do they consume per day? If risky behaviour has been identified, clinicians can offer counselling and feedback using the FRAMES approach:

• Feedback of risk
• Responsibility for change
• Advice
• Menu of options
• Empathy
• Self-efficacy

The approach can range from 5 minutes to 15 minutes with or without follow-up contact over several weeks or months to providing materials to help change behaviour and strategies to cut down drinking. If drinking habits worsen, the authors recommend referral for more specialized treatment.

Although some health care professionals may find it awkward to initiate these conversations, "patients may appreciate receiving an intervention in a primary care or hospital setting, which can be less embarrassing, stigmatizing or inconvenient than consulting an addiction specialist or entering a formal alcohol treatment program," according to the authors.

"Canadians with at-risk drinking and alcohol use disorders rarely receive any of these effective interventions," writes Dr. Sheryl Spithoff, a family physician at Women's College Hospital, with Dr. Suzanne Turner, St. Michael's Hospital, Toronto, Ontario, in a related commentary (pre-embargo link only) http://www.cmaj.ca/site/press/cmaj.140849.pdf.

In Canada, addiction education is scant in medical schools, few primary care clinics or emergency departments routinely screen patients for alcohol misuse, and many hospitals lack an addiction medicine service. Medications, which can be effective for more severe alcohol misuse and cost-effective, are often not prescribed.

To ensure better access to alcohol screening and interventions, the authors recommend the following policy changes:

• Training on alcohol misuse should be incorporated into medical education for medical students and residents.
• Provinces and territories should compensate physicians appropriately using billing codes that reflect the complexity of alcohol misuse interventions.
• Hospitals and primary care clinics should implement screening and intervention programs as well as pathways to connect those with more severe problems to ongoing treatment.
• Provinces and territories should fund first-line medications for alcohol use disorders (naltrexone and acamprosate) and make them widely accessible on the public formulary.

The authors state that these "policy changes would help to ensure equitable care for those with at-risk drinking and alcohol use disorders, thereby reducing the burden of disease and saving costs."