Jan. 14, 2008 A 10-minute screening and talk with a doctor about problem drinking delivers almost as much bang for the buck to the health system as childhood immunization and advice about taking aspirin to prevent stroke and heart attack, according to a new systematic review — but just 8.7 percent of problem drinkers report receiving such information.
The review, which appears in the February issue of the American Journal of Preventive Medicine, included data from 10 randomized controlled trials of alcohol problem screening and advice by primary care doctors.
“Reviewing this data and stepping back, it really struck me how truly important this finding is,” said lead author Leif Solberg, M.D., associate medical director for care improvement research at Health Partners in Minneapolis. “It’s a service most physicians don’t offer.” Solberg added that most doctors now recognize the importance of offering advice on quitting smoking, but with drinking, physicians are not onboard.
“I think most of my fellow physicians would think that their impact on alcohol use is close to zero,” he says.
“Alcohol screening and brief therapy are very cost-effective compared to other recommended medical services, yet they are employed least often of any of them,” said Alex DeLuca, M.D., former chief and medical director of the Smithers Addiction Treatment and Research Center in New York, who was not involved with the systematic review.
Brief intervention for alcohol is in the top-five most cost-effective preventive services, according to the research — coming in equal to or higher than many common screening services like Pap smears and bowel cancer screening.
DeLuca said of the review, “The analysis of cost-effectiveness was sophisticated and appropriate, and the calculations for alcohol services were comparable to the other services, supporting the relevance of the overall model and methodology used. The article supports prioritizing alcohol screening and counseling.”
The review found that screening and brief counseling reduced problem drinking by 17.4 percent over a period that varied from six months to two years among studies. This means that more than one in six problem drinkers who received these brief interventions no longer fit that definition six months to two years later.
Although that might seem like a small reduction, with one-fourth of people aged 18 to 54 engaging in problem drinking, cutting the numbers by that amount results in a large effect on the population as a whole.
Review studies relied on different definitions of problem drinking, but the task force viewed it as drinking more than seven drinks per week for women or more than 14 for men — or drinking more than three drinks on one occasion for women or four drinks per occasion for men. It includes risky behaviors such as drinking and driving, and binge drinking, which are not severe enough to meet the criteria for alcoholism or alcohol dependence.
Some reasons physicians tend not to screen for alcohol problems in general practice are a sense that a short talk with a doctor will not help alcoholics quit and a perception that those who are not alcoholics do not need advice on cutting back or stopping drinking.
However, Solberg said, “The value of this service comes without the difficulty of treating dependence — this is problem drinking.” Study co-author, Michael Maciosek, Ph.D., research investigator at Health Partners, added, “The effectiveness does not depend on stopping drinking — it’s reducing the quantity or the number of times there is binge drinking.”
DeLuca said that many physicians are afraid of getting involved in “lengthy, uncomfortable encounters” with patients who could be defensive about drinking too much and they are generally pessimistic about the outcomes of treatment for alcohol problems, despite the strong research support for both brief interventions for problem drinkers and other therapies for alcoholics.
In terms of costs, the review found that each screening and counseling session cost about $10 per patient and saved the health care system about the same amount over five years in terms of reduced costs due to accidents, injuries and other alcohol-related health problems. It did not include savings due to possible health benefits of moderate drinking.
“Physicians do not screen for substance use disorders enough or provide brief counseling – even though if they did, many, many people would be spared much misery and illness and cost. So, patients, if the docs won’t bring it up, you should,” DeLuca advised.
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