The importance of alcohol screening, brief intervention, and referral to treatment in closing the alcohol use disorder treatment gap
This article was first published in NIAAA Spectrum Volume 15, Issue 2.
Decades of research have firmly established the importance of asking primary care patients about their alcohol use, providing brief advice about reducing alcohol misuse, and referring them to appropriate alcohol treatments, as necessary. Studies consistently find that these practices, known collectively as alcohol screening, brief intervention, and referral to treatment (SBIRT), can be used effectively by providers across the health care spectrum to prevent or reduce alcohol misuse among their patients. Studies show that most patients do not object to being screened, that they are open to hearing advice, and that those who screen positive for heavy drinking or alcohol use disorder (AUD) show some motivational readiness to change.
”Nearly 30 million people in the U.S. reach criteria for AUD, but less than 1 in 10 receive treatment of any kind each year,” said National Institute on Alcohol Abuse and Alcoholism (NIAAA) Director George F. Koob, Ph.D. “These statistics emphasize the importance of widespread implementation of and access to alcohol SBIRT across health care and community settings.”
NIAAA-supported researchers and other scientists recently analyzed several years of data from the National Survey on Drug Use and Health to examine basic screening, advice, and referral to treatment for people with AUD.1 They found that from 2015 to 2019, 81.4% of people with AUD saw a clinician in the past year and 69.9% were asked at least one question about their alcohol consumption, most likely on an intake form (screening). Among the people with AUD who were screened, only 11.6% were offered advice or information (brief intervention) and 5.1% were advised about treatment options or given other resources (referral to treatment). Although people with severe AUD were more likely to receive brief intervention or referral to treatment, these data clearly indicate that routine health care visits represent missed opportunities to help close the AUD treatment gap.
Tools and techniques that providers need for conducting alcohol SBIRT with their patients can be found in the Healthcare Professional’s Core Resource on Alcohol (HPCR). Released in 2022, the HPCR provides health care professionals with helpful information for addressing alcohol consumption among their patients. The HPCR carefully describes the steps of alcohol SBIRT, why they are important, and how health care providers can support patients in recovery.
The HPCR encourages the routine integration of an Alcohol Symptom Checklist to make it easier for clinicians to hold comfortable, patient-centered, nonjudgmental conversations about alcohol that help destigmatize AUD and its treatment. The Alcohol Symptom Checklist is a questionnaire that asks patients to self-report whether, within the past year, they have experienced each of the 11 AUD criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5). A team led by NIAAA grantees Dr. Kevin A. Hallgren and Dr. Katharine A. Bradley at the University of Washington recently conducted a series of studies evaluating the Alcohol Symptom Checklist. They found that the checklist had good to excellent reliability when it was completed by patients as part of routine care after screening positive for alcohol misuse.2 The checklist performed well across age, sex, race, and ethnicity subgroups, and could detect AUD symptoms for many patients who reported alcohol misuse but had not been previously diagnosed with AUD.3 Among primary care patients who reported alcohol misuse, those who screened positive for depression had more than a 40% higher prevalence of probable AUD based on Alcohol Symptom Checklist scores, compared to patients who did not screen positive for depression (69.8% vs. 48.0%, respectively).4
“Alcohol contributes to more than 200 diseases and adverse health conditions, and often precedes diagnoses of mental health conditions. This means that screening for alcohol misuse can help clinicians address a broad range of health conditions, in addition to AUD, and improve their ability to serve their patients. Health care professionals are in a prime position to make a difference,” said Dr. Koob. “We want all providers to know about alcohol SBIRT, and to use it.”
For more information about the HPCR, including the opportunity for health care professionals to earn free continuing education credits, visit niaaa.nih.gov.
References:
1 Mintz CM, Hartz SM, Fisher SL, Ramsey AT, Geng EH, Grucza RA, Bierut LJ. A cascade of care for alcohol use disorder: using 2015-2019 National Survey on Drug Use and Health data to identify gaps in past 12-month care. Alcohol Clin Exp Res. 2021 Jun;45(6):1276-1286. PubMed PMID: 33993541
2 Hallgren KA, Matson TE, Oliver M, Caldeiro RM, Kivlahan DR, Bradley KA. Practical assessment of DSM-5 alcohol use disorder criteria in routine care: high test-retest reliability of an Alcohol Symptom Checklist. Alcohol Clin Exp Res. 2022 Mar;46(3):458-467. PubMed PMID: 35275415
3 Hallgren KA, Matson TE, Oliver M, Witkiewitz K, Bobb JF, Lee AK, Caldeiro RM, Kivlahan D, Bradley KA. Practical assessment of alcohol use disorder in routine primary care: performance of an Alcohol Symptom Checklist. J Gen Intern Med. 2022 Jun;37(8):1885-1893. PubMed PMID: 34398395
4 Ryan ED, Chang YM, Oliver M, Bradley KA, Hallgren KA. An Alcohol Symptom Checklist identifies high rates of alcohol use disorder in primary care patients who screen positive for depression and high-risk drinking. BMC Health Serv Res. 2022 Sep 5;22(1):1123. PubMed PMID: 36064354