Screening and Brief Intervention for Alcohol Misuse in Primary Care: What Comes After the Screening Validation Studies and rct’s

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  • Screening and Brief Intervention for Alcohol Misuse in Primary Care:

  • What Comes After the Screening Validation Studies and RCT’s

  • CJ 556; 10/17/07

VA Motto: Lincoln’s 2nd Inaugural March 4, 1865

  • “With malice toward none, with charity for all, with firmness in the right

  • as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds,

  • to care for him [sic] who shall have borne the battle and for his [sic] widow, and his [sic] orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.”

Veterans Health Administration

  • - US largest integrated healthcare system

  • - >5M veterans served in FY07

  • - 157 medical centers

  • - 721 community-based outpatient clinics

  • - 21 regions

Infrastructure Advantages of VA

  • National systems for administrative data

  • Integrated electronic health record

  • VA Office of Quality and Performance

    • Incentivized performance monitoring
    • Evidence-based treatment guidelines
  • VA Health Services Research

    • QUERI


  • Select patient populations

  • Identify E-B Guidelines/Recommendations

  • Assess Performance Gaps

  • Design/Implement Improvement Programs

  • Evaluate impact on clinical outcomes

  • Evaluate impact on health-related quality of life

Unique patients with SUD seen in VA 2002-2006

Perceived Need for Treatment of SUD: NSDUH 2006

Where Past Year Substance Use Treatment Was Received: 2006

Goals of SUD QUERI

  • Improve detection and mgmt of alcohol misuse in primary care

  • Improve retention of patients in continuing specialty care for SUD

  • Implement effective smoking cessation treatment

  • Improve detection and mgmt of patients with SUDs and SUD-related co-occurring disorders seen in primary care and other medical settings

    • infectious disease (i.e., HIV, Hepatitis C)
    • psychiatric co-morbidity

The Spectrum of Alcohol Use

What is Alcohol Dependence?

  • 3 or more of these criteria in

  • a 12-month period:

    • 1. Tolerance
    • 2. Withdrawal
    • 3. More or longer consumption than intended
    • 4. Cannot cut down or control alcohol use
    • 5. A great deal of time getting, using, recovering
    • 6. Activities given up or reduced
    • 7. Use despite knowledge of health problem

Characteristics of 5 empirically-derived AD subtypes in the U.S. population (Moss et al. in press, Drug & Alc Dep)

What is Alcohol Misuse?

  • Drinking above NIAAA recommended limits

    • OR
  • Diagnosis of abuse or dependence

  • Together referred to as “alcohol misuse”

NIAAA recommended limits (US standard drink ~ 14 g alcohol)

    • Men > 14 drinks/week or
    • > 4 drinks/occasion
    • Women > 7 drinks/week or
      • > 3 drinks/occasion

How to Detect Alcohol Misuse?

  • Biomarkers

  • Self-report

New Biomarkers of Excess Alcohol?

  • Carbohydrate-Deficient Transferrin (CDT)

  • Ethylglucuronide (EtG)

  • Transdermal devices

  • Composite index from blood serum panel

  • Hemoglobin Associated Acetaldehyde

  • Fatty Acid Ethyl Esters (in hair)

Limitations of biological assays

  • Cost and logistics

  • Invasiveness

  • Lack of sensitivity - timing

Self-Report Alcohol Misuse Screens

  • CAGE (4 items)

  • MAST (10-25 items)

    • Michigan Alcoholism Screening Test
  • AUDIT (10 items)

    • Alcohol Use Disorders Identification Test

The CAGE Questions

  • Have you ever felt you should Cut down on your drinking?

  • Have people Annoyed you by criticizing your drinking?

  • Have you ever felt bad or Guilty about your drinking?

  • Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?

Alcohol Misuse Screening


Do Patients Accurately Report Drinking?

Screening for Hazardous Drinking or Alcohol Abuse or Dependence

AUDIT-C Score Reflects Risk

AUDIT-C Summary

  • Score reflects severity and readiness to change

  • Score may not accurately measure alcohol exposure (marker vs. measure)

  • Can be used to risk-stratify for:

    • Brief alcohol counseling
    • Specialty care referral

Why Screen for Alcohol Misuse?

  • Risk for adverse health outcomes (multiple studies; meta-analyses)

  • Indication for brief alcohol counseling (BAC) that reduces alcohol consumption

  • 2006 National Commission on Prevention Priorities identified BAC among top 10 prevention activities

Risk for adverse health outcomes

  • Chronic heavy alcohol use

  • Liver disease 2 drinks/day (m)

  • Hypertension 3 drinks/day (m/w)

  • Stroke 4 drinks/day (m/w)

  • Mortality 4 drinks/day (m)

  • Episodic heavy drinking

  • Injury 5 drinks/occasion (m)

  • STDs 4 drinks/occasion (w)

Why Screen for Alcohol Misuse?

  • Risk for adverse health outcomes (multiple studies; meta-analyses)

  • Indication for brief alcohol counseling (BAC) that reduces drinking risk

  • 2006 National Commission on Prevention Priorities identified BAC among top 10 prevention activities

Authors' conclusions

  • 28 controlled trials from various countries

    • general practice (23 trials) or an emergency setting (5 trials).
  • At trial entry, participants drank an average of 320 grams/week

    • over 30 standard European drinks
  • N> 7000 randomized to receive a brief intervention (BI) or a control intervention, including assessment only.

  • At one year's follow up (17 trials), people who had received the BI drank less alcohol (mean difference of 41 grams).

  • For men, the benefit of brief intervention was a reduction of 57 grams/week (range 25 to 89 grams).

  • The benefit was not clear for women.

  • Longer duration of counseling probably has little additional effect.

Why Screen for Alcohol Misuse?

  • Risk for adverse health outcomes (multiple studies; meta-analyses)

  • Indication for brief alcohol counseling (BAC) that reduces drinking risk

  • 2006 National Commission on Prevention Priorities identified BAC among top 10 prevention activities

Priorities among Clinical Prevention Services (Maciosek et al, Am J Prev Med 2006)

  • Service

  • Aspirin chemoprophylaxis

  • Childhood immunization series

  • Tobacco screening and Brief Int.

  • Colorectal concern screening

  • Hypertension screening

  • Influenza immunization

  • Pneumocacal immunization

  • Alcohol misuse Screening & Brief Intervention (SBI)

  • Vision screening

  • Cervical cancer screening

  • Cholesterol screening

  • Breast cancer screening

Benefits of Brief Alcohol Counseling

    • 2007 Cochrane review and 9 other meta-analyses have demonstrated efficacy
      • especially in men
    • One of the top 10 US prevention priorities
    • US: NNT 7-9 to move one patient from risky to non-risky drinking
    • After 4 years, for every $1.00 spent on brief alcohol counseling, $4.30 saved on inpatient and emergency care

Helping Patients Who Drink Too Much: 5 A’s

  • ASK about alcohol use

  • ASSESS severity and readiness to change

  • ADVISE cutting down or abstinence, and assist in goal setting

  • ASSIST with further treatment when necessary

  • ARRANGE follow-up to monitor progress

Express Empathy

  • Express Empathy

  • Develop Discrepancy

  • Avoid Argumentation

  • Roll with Resistance

  • Support Self-Efficacy


  • Respect client autonomy, culture and choices.

  • Acknowledge client as the active decision maker.

  • Negotiate an agenda for change.

  • Offer information in a neutral, non-personal manner.

  • Ask open-ended questions.

  • Practice reflective listening to encourage patients to talk about their drinking and the barriers to change.

  • Accept resistance as a normal response.

  • Avoid confrontation, labeling, stereotyping and forcing patients to accept a label or diagnosis.

Demystifying Motivational Interviewing for SUD

  • “So this weekend I went into a store to buy some paint…The fellow at the counter…saw ‘CASAA’ on my shirt and asked what it is. I told him it’s an addiction treatment research center…he said, ‘I help people with that problem sometimes.’

  • “Really? What do you do?”

  • Bill Miller e-mail to MI Network of Trainers 3/29/05

Demystifying Motivational Interviewing for SUD

  • “I just talk to them… I just do volunteer counseling. I help them see that they have a choice. We lay out the two sides – what happens if they continue on as they are, and what else they could do. And then I ask them which way they want to go. I don’t tell them what to do. It has to come from them. That’s what I do, and it just seems to help.”

  • He had a 6th grade education

  • Bill Miller e-mail to MI Network of Trainers 3/29/05

Promoting Action on Research Implementation in Health Services (PARIHS)

2 “Simple” Principles of Facilitation

  • Feedback on local performance

    • carefully defined
    • accurately measured
    • ongoing
  • Accessible supervision or “coaching” from someone with more expertise about improvement

How to Measure Performance for Brief Alcohol Counseling ?

  • No established performance measures

  • No health care system has implemented brief alcohol counseling effectively

  • VA is leader in routine alcohol screening

  • WHO study to implement brief alcohol counseling found rates so low, 10% considered “excellent”

Data Sources for BAC Performance Measure: Limits and Feasibility

Self-reported Alcohol-related Advice If Screen+ for Alcohol Misuse

Developing a Brief Alcohol Counseling Performance Measure

  • Evidence is strongest in non-dependent alcohol misuse, but recommended for all alcohol misuse – need to risk-stratify

  • Key components of BAC:

    • Advice: abstain or decrease drinking below limits
    • Feedback linking drinking to health
  • Completed specialty referral also acceptable follow-up of screening results

A Measure of Brief Alcohol Counseling Based on Medical Record Review

Scores of 5-7 (moderate risk)

    • Most patients NOT alcohol dependent
    • However, history of alcohol treatment increases risk

AUDIT-C Scores 8-12 (severe risk)

Alcohol Counseling Clinical Reminder


  • Implemented screening for alcohol misuse

  • Need appropriate follow-up

    • Brief alcohol counseling or completed referral
    • Higher than other health care systems, but much room for improvement
    • Developed new performance measure
  • Clinical reminder improves documented BAC

    • Increased documented counseling: 55-70%
    • Especially increased rates in mild/moderate abuse who might benefit most
  • What about reduced risk?

If you cannot measure it, you cannot improve it.

  • “If you can measure that of which you speak and express it in numbers,

  • you know something about your subject;

  • but if you cannot measure it,

  • your knowledge is of a very meager and unsatisfactory kind.” (1883)

  • William Thomson (Lord Kelvin) (1824-1907).

Research Team

  • Kathy Bradley, MD

  • Carol Achtmeyer, ARNP

  • Anna DeBenedetti, BA

  • Gwen Greiner, MPH

  • Eric Hawkins, PhD

  • Emily Williams, MPH

  • Funding from


  • VA HSR&D

  • NIAAA R21AA14672

BAC & MI Web Resources

  • Brief alcohol counseling

  • 4 minute Boston University demo video (Case 3 at:

  • NIAAA Clinicians Guide – updated 2007

  • Motivational Interviewing

  • 8 training videotapes:

  • NIDA trainings including MI:


  • Biomarkers pf Alcohol Misuse

  • Bean, P. Update on new biomarkers for detecting excessive alcohol use. November 2002. Available at:

  • Wolff, K, Farrell, M, Marsden, J: A review of biological indicators of illicit drug use: Practical considerations and clinical usefulness. Addiction, 94:1279-98, 1999

  • Screening Validity of AUDIT and AUDIT-C

  • Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro M. AUDIT - The Alcohol Use Disorders Identification Test: Guidelines for use in primary health care. World Health Organization, 2001

  • Bradley, K.A., Bush, K., Epler, A., Dobie, D., Davis, T., Sporleder, J., Maynard, C., Burman, M. & Kivlahan, D. (2003). Two brief alcohol screening tests from the Alcohol Use Disorders Identification Test (AUDIT): Validation in a female VA patient population, Arch Int Med, 163, 821-829

  • Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA: The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Arch Intern Med 158:1789-1795, 1998

  • Association of AUDIT-C and Health Outcomes

  • Au DH, et al. Alcohol Screening Scores and Risk of Hospitalizations for GI Conditions in Men. Alcoholism, clinical and experimental research 2007;31:443-451

  • Bradley KA, et al. The relationship between alcohol screening questionnaires and mortality among male veteran outpatients. J Stud Alcohol 2001;62:826-833

  • Bradley, KA, et al. (2004). "Using alcohol screening results and treatment history to assess the severity of at-risk drinking in VA primary care patients." Alcohol Clin Exp Res 28(3): 448-455.

  • Reviews on BI/BAC

  • Kaner E, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev 2007:CD004148 (Nice Cochrane review of brief alcohol counseling.)

  • Maciosek MV, et al. Priorities among effective clinical preventive services results of a systematic review and analysis. Am J Prev Med 2006;31:52-61 (Established brief alcohol counseling one of top 10 US prevention priorities)

  • NIAAA Clinicians Guide – updated 2007 (Includes DSM criteria for alcohol use disorders and review of medications for alcohol dependence.)

  • Whitlock EP, et al. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140:557-568 (Nice USPSTF review of evidence for brief alcohol counseling)

  • Important RCT

  • Fleming MF. Letters: Brief physician advice for problem alcohol drinkers. JAMA 1997;278:1059-1060. Economic analyses: Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcoholism, clinical and experimental research 2002;26:36-43

  • Implementation and Performance Measurement

  • Greenhalgh, T., et al., (2004). Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 82(4):581-629

  • Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care 1998;7:149–58

  • Miller WR, Sorensen JL, Selzer JA, Brigham GS. Disseminating evidence-based practices in substance abuse treatment: a review with suggestions. J. Subst Abuse Treat. 2006 31, 25-39.

  • Pincus, H., et al. (2007). Can psychiatry cross the quality chasm? Improving the quality of health care for mental and substance use conditions. Am J Psychiatry,164(5):712-9.

  • VA Quality Enhancement Research Initiative (QUERI)

  • Tisnado DM, Adams JL, Liu H, Damberg CL, Chen WP, Hu FA, Carlisle DM, Mangione CM, Kahn KL.What is the concordance between the medical record and patient self-report as data sources for ambulatory care? Med Care. 2006 Feb;44(2):132-40.

Contact information

  • Daniel Kivlahan, PhD

  • Director, CESATE

  • Clinical Coordinator, SUD QUERI

  • VA Puget Sound Health Care System

  • Phone: 206-768-5483

  • E-Mail:


The Clients Perspective

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