Grade: B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
The USPSTF recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use.
Frequency of Service
The USPSTF did not find adequate evidence to recommend an optimal screening interval for unhealthy alcohol use in adults. Brief behavioral counseling interventions were found to reduce unhealthy alcohol use in adults 18 years or older, including pregnant women. Effective behavioral counseling interventions vary in their specific components, administration, length, and number of interactions. The USPSTF was unable to identify specific intervention characteristics or components that were clearly associated with improved outcomes.
Risk Factor Information
engaged in risky or hazardous drinking
The “B” recommendation applies to adults 18 years or older, including pregnant women. The “I” statement applies to adolescents aged 12 to 17 years. These recommendations do not apply to persons who have a current diagnosis of or who are seeking evaluation or treatment for alcohol abuse or dependence.
Of the available screening tools, the USPSTF determined that 1- to 3-item screening instruments have the best accuracy for assessing unhealthy alcohol use in adults 18 years or older.1 These instruments include the abbreviated Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) and the NIAAA-recommended Single Alcohol Screening Question (SASQ).
The abbreviated AUDIT-C has good sensitivity and specificity for detecting the full spectrum of unhealthy alcohol use across multiple populations.1,9 The AUDIT-C has 3 questions about frequency of alcohol use, typical amount of alcohol use, and occasions of heavy use, and takes 1 to 2 minutes to administer. The USAUDIT and USAUDIT-C are based on US standards. Preliminary evidence (1 study) suggests that the USAUDIT (specifically the USAUDIT-C) may be more valuable in identifying at-risk college drinkers.10 The SASQ also has adequate sensitivity and specificity across the unhealthy alcohol use spectrum and requires less than 1 minute to administer, asking “How many times in the past year have you had 5 [for men] or 4 [for women and all adults older than 65 years] or more drinks in a day?”1,2 The Cut down, Annoyed, Guilty, Eye-opener (CAGE) tool is well known but only detects alcohol dependence rather than the full spectrum of unhealthy alcohol use.1,11
When patients screen positive on a brief screening instrument (eg, SASQ or AUDIT-C), clinicians should ensure follow-up with a more in-depth risk assessment to confirm unhealthy alcohol use and determine the next steps of care. Evidence supports the use of brief instruments with higher sensitivity and lower specificity as initial screening, followed by a longer instrument with greater specificity (eg, AUDIT). The AUDIT has 10 questions: 3 questions covering frequency of alcohol use, typical amount of alcohol use, and occasions of heavy use, and 7 questions on the signs of alcohol dependence and common problems associated with alcohol use (eg, being unable to stop once you start drinking). It requires approximately 2 to 5 minutes to administer.1,12 If AUDIT is used as an initial screening test, clinicians may use a lower cutoff (such as 3, 4, or 5) to balance sensitivity and specificity in screening for the full spectrum of unhealthy alcohol use.
Screening instruments have also been specifically developed for various populations. Screening tools for pregnant women include Tolerance, Worried, Eye-opener, Amnesia, Kut down (TWEAK)13; Tolerance, Annoyed, Cut down, Eye-opener (T-ACE)14; Parents, Partner, Past, Present Pregnancy (4P’s Plus)15; and Normal drinker, Eye-opener, Tolerance (NET).16 The NIAAA and American Academy of Pediatrics recommend the Car, Relax, Alone, Forget, Family, Friends, Trouble (CRAFFT) screening instrument for identifying risky substance use in adolescents.17 The NIAAA also recommends asking patients about their own alcohol use as well as their friends’ alcohol use.5 The Comorbidity Alcohol Risk Evaluation Tool (CARET) is used in older adults.18 The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), developed by the World Health Organization (WHO), screens for substance and alcohol use in adults.1,19
Behavioral Counseling Interventions
Behavioral counseling interventions for unhealthy alcohol use vary in their specific components, administration, length, and number of interactions. Thirty percent of the interventions reviewed by the USPSTF were web-based. Nearly all of the interventions consisted of 4 or fewer sessions; the median number of sessions was 1 (range, 0-21). The median length of time of contact was 30 minutes (range, 1-600 minutes). Most of the interventions had a total contact time of 2 hours or less.1 Primary care settings often used the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach. Interventions targeting adults other than college students (including pregnant and postpartum women) were more likely to take place in primary care settings, have multiple sessions, and involve a primary care team.1 Most interventions involved giving general feedback to participants (eg, how their drinking fits with recommended limits, or how to reduce alcohol use). The most commonly reported intervention component was use of personalized normative feedback sessions, in which participants were shown how their alcohol use compares with that of others; more than half of the included trials and almost all trials in young adults used this technique.1 Most trials in young adults involved 1 or 2 in-person or web-based personalized normative feedback sessions in university settings. Personalized normative feedback was often combined with motivational interviewing or more extensive cognitive behavioral counseling. Other cognitive behavioral strategies, such as drinking diaries, action plans, alcohol use “prescriptions,” stress management, or problem solving were also frequently used. About one-third of the intervention trials in general and older adult populations involved a primary care team.1 The USPSTF was unable to identify specific intervention characteristics or components that were clearly associated with improved outcomes.1
The USPSTF found no evidence to suggest that patients of different race/ethnicity or lower socioeconomic status have a lower likelihood of benefit from interventions. Effects of interventions were also similar in men and in women.1
The USPSTF did not find adequate evidence to recommend an optimal screening interval for unhealthy alcohol use in adults.
Suggestions for Practice Regarding the I Statement
Potential Preventable Burden
In 2016, the National Survey on Drug Use and Health reported that an estimated 9.2% of adolescents aged 12 to 17 years drink alcohol and 4.9% had an episode of binge drinking in the last 30 days.20 Each year, excessive drinking in underage youth leads to more than 4300 deaths.21 Driving while under the influence of alcohol is particularly hazardous among adolescents. The 2015 Youth Risk Behavior Survey found that about 8% of high school students who drove a car in the last 30 days reported driving after drinking alcohol, and 20% reported riding with a driver who had been drinking.22 In 2010, 1 in 5 teen drivers involved in a fatal motor vehicle collision had some alcohol in their system, and most had blood alcohol levels higher than the legal limit for adults.23 An estimated 97,000 students aged 18 to 24 years have reported an alcohol-related sexual assault or date rape; 696,000 students aged 18 to 24 years have been assaulted by another student who was under the influence of alcohol.24,25 An estimated 1 in 4 college students report academic consequences from drinking such as missing class, doing poorly on examinations or papers, falling behind in class, and receiving lower grades.1,24,26
Possible harms of screening for unhealthy alcohol use include stigma, anxiety, labeling, discrimination, privacy concerns, and interference with the patient-clinician relationship. The USPSTF did not find any evidence that specifically examined the harms of screening for alcohol use in adolescents.
Research suggests that although a majority of pediatricians and family practice clinicians report providing some alcohol prevention services to adolescent patients, they do not consistently screen and counsel for alcohol misuse.27 Survey results indicate that screening was more likely if adolescents were older (aged 15 to 17 years).27 However, the quality of screening practices, tools used, and interventions provided varied widely. Current data on rates of screening are lacking. Reported barriers to screening include time constraints, lack of knowledge about best practices, and lack of services for adolescent patients who screen positive.1,28
The AUDIT and AUDIT-C, which screen for unhealthy alcohol use in adults 18 years or older, including pregnant women, are available from the Substance Abuse and Mental Health Service Administration (SAMHSA), as well as other resources.29,30 More information about SASQ and counseling for unhealthy alcohol use is available from the NIAAA.31 Clinician guides are available from the WHO32 and the American Academy of Family Physicians.33 An implementation guide for primary care practices is available from the Centers for Disease Control and Prevention.34
The Community Preventive Services Task Force recommends electronic screening and brief interventions to reduce excessive alcohol consumption in adults. It found limited information on the effectiveness of electronic screening and brief interventions in adolescents.35 The Community Preventive Services Task Force has also evaluated public health interventions (ie, interventions occurring outside of the clinical practice setting) to prevent excessive alcohol consumption.36
The USPSTF has made recommendations on screening for and interventions to reduce the unhealthy use of other substances, including illicit drugs37 and tobacco.38
Research Needs and Gaps
The USPSTF has identified several research gaps. Although difficult, conducting a trial with an unscreened comparison group to understand the population-level effects of screening in primary care settings would be valuable. More direct evidence is needed on the harms associated with screening and behavioral interventions. The USPSTF found a preliminary study that evaluated the USAUDIT and USAUDIT-C, recent US adaptations of the AUDIT and AUDIT-C. Further test performance studies are needed to confirm their accuracy in identifying unhealthy alcohol use in various populations. More evidence on important clinical outcomes is needed, such as longer-term morbidity, mortality, health care utilization, and social and legal outcomes. Trials designed a priori to report subgroup effects in diverse populations (eg, by age, sex, race/ethnicity, or baseline severity) would be useful. Limited evidence is available to assess the effects of screening and behavioral counseling in adolescents, and high-quality studies specifically addressing this population are needed. In addition, studies in adolescents are often conducted in school settings, which may not translate to primary care settings. More studies of adolescents in primary care settings are needed.
Update of Previous USPSTF Recommendation
This recommendation replaces the 2013 USPSTF recommendation statement on screening and behavioral counseling interventions for alcohol misuse. The term “alcohol misuse,” used in the 2013 recommendation, has been replaced by the term “unhealthy alcohol use.”
The USPSTF uses the term “unhealthy alcohol use” to define a spectrum of behaviors, from risky drinking to alcohol use disorder (AUD) (eg, harmful alcohol use, abuse, or dependence) (Table).1 “Risky” or” hazardous” alcohol use means drinking more than the recommended daily, weekly, or per-occasion amounts, resulting in increased risk for health consequences but not meeting criteria for AUD.2 The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines “risky use” as exceeding the recommended limits of 4 drinks per day (56 g/d based on the US standard of 14 g/drink) or 14 drinks per week (196 g/d) for healthy adult men aged 21 to 64 years or 3 drinks per day or 7 drinks per week (42 g/d or 98 g/week) for all adult women of any age and men 65 years or older.2
A standard drink is defined as 12.0 oz of beer (5% alcohol), 5.0 oz of wine (12% alcohol), or 1.5 oz of liquor (40% alcohol).2 The American Society of Addiction Medicine (ASAM) defines “hazardous use” as alcohol use that increases the risk of future negative health consequences.3 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines the severity of AUD (mild, moderate, or severe) based on the number of criteria met.4 Previous versions of the DSM-5 had separate diagnoses for alcohol abuse and alcohol dependence, but it no longer separates these diagnoses.1 Currently, there is no firm consensus worldwide regarding the definition of risky drinking. In addition, the definition of a standard drink differs by country.1 Any alcohol use is considered unhealthy in pregnant women and adolescents.1 In adolescents, the definition of moderate- or high-risk alcohol use varies by age, based on days of use per year.5
Excessive alcohol use is one of the most common causes of premature mortality in the United States. From 2006 to 2010, an estimated 88,000 alcohol-attributable deaths occurred annually in the United States, caused by both acute conditions (eg, injuries from motor vehicle collisions) and chronic conditions (eg, alcoholic liver disease).1,6 Alcohol use during pregnancy is also one of the major preventable causes of birth defects and developmental disabilities.7
The USPSTF found adequate evidence that numerous brief screening instruments can detect unhealthy alcohol use with acceptable sensitivity and specificity in primary care settings.
Benefits of Early Detection and Behavioral Counseling Interventions
The USPSTF found no studies that directly evaluated whether screening for unhealthy alcohol use in primary care settings in adolescents and adults, including pregnant women, leads to reduced unhealthy alcohol use; improved risky behaviors; or improved health, social, or legal outcomes.
The USPSTF found adequate evidence that brief behavioral counseling interventions in adults who screen positive are associated with reduced unhealthy alcohol use. There were reductions in both the odds of exceeding recommended drinking limits and heavy use episodes at 6- to 12-month follow-up. In pregnant women, brief counseling interventions increased the likelihood that women remained abstinent from alcohol use during pregnancy. The magnitude of these benefits is moderate. Epidemiologic literature links reductions in alcohol use with reductions in risk for morbidity and mortality and provides indirect support that reduced alcohol consumption may help improve some health outcomes.1,8
The USPSTF found inadequate evidence that brief behavioral counseling interventions in adolescents were associated with reduced alcohol use.
Harms of Screening and Behavioral Counseling Interventions
The USPSTF bounds the harms of screening and brief behavioral counseling interventions for unhealthy alcohol use in adults, including pregnant women, as small to none, based on the likely minimal harms of the screening instruments, the noninvasive nature of the interventions, and the absence of reported harms in the evidence on behavioral interventions. When direct evidence is limited, absent, or restricted to select populations or clinical scenarios, the USPSTF may place conceptual upper or lower bounds on the magnitude of benefit or harms.
The USPSTF found inadequate evidence on the harms of screening and brief behavioral counseling interventions for alcohol use in adolescents.
The USPSTF concludes with moderate certainty that screening and brief behavioral counseling interventions for unhealthy alcohol use in the primary care setting in adults 18 years or older, including pregnant women, is of moderate net benefit.
The USPSTF concludes that the evidence is insufficient to determine the benefits and harms of screening for unhealthy alcohol use in the primary care setting in adolescents aged 12 to 17 years.
Recommendations of OthersThe US Surgeon General,52 NIAAA,2 Centers for Disease Control and Prevention,34 and ASAM53 recommend routinely screening adult patients for unhealthy alcohol use and providing them with appropriate interventions, if needed. The US Department of Veterans Affairs recommends annual screening with the AUDIT-C and SASQ.54 The American Academy of Pediatrics recommends screening all adolescent patients for alcohol use with a formal, validated screening tool (such as the CRAFFT) at every health supervision visit and appropriate acute care visits, and responding to screening results with the appropriate brief intervention and referral if indicated. Pediatricians should become familiar with adolescent SBIRT approaches and their potential for incorporation into universal screening and comprehensive care of adolescents in the medical home.55 The American College of Obstetricians and Gynecologists56 and WHO57 recommend screening all women for unhealthy alcohol use before pregnancy and in their first trimester with a validated tool, and offering a brief intervention to all pregnant women who use alcohol.
- JAMA Patient Page: Screening and Counseling to Reduce Unhealthy Alcohol Use
- Screening and Behavioral Counseling Intervention to Reduce Unhealthy Alcohol Use in Adolescents and Adults: AFP's Putting Prevention Into PracticeThe journal American Family Physician (AFP) provides a series of short case studies and quizzes based on recommendations issued by the U.S. Preventive Services Task Force.