In a recent National Public Radio commentary, Dr. Elisabeth Poorman suggests that primary care doctors could do more to identify and address alcoholism in their patients.
Even though doctors have been trained and encouraged to screen patients for alcoholism since 1990, only 1 in 6 patients report talking with a doctor, nurse, or health care professional about their drinking. “With all of our incredible medical advances, we have utterly failed to combat the growing plague of addiction,” Poorman writes. “And while opioid disorders are gaining more attention, alcohol still kills more people than all illicit drugs combined.”
CDC Director, Dr. Tom Frieden, agrees. He says that even though only about 4% of the U.S. population is alcohol dependent, about 30% of adults misuse alcohol. This misuse is dangerous and associated with an array of health problems: heart disease, breast cancer, fetal alcohol spectrum disorders, motor vehicle crashes, and more.
Why Do Doctors Neglect To Screen Their Patients?
According to an article in Medscape, doctors confessed shirking alcohol use screening because of time constraints, worries about patient compliance, and a belief that screenings aren’t effective. In addition, as Poorman argues, a large part of the problem is the way doctors (and the general population) define “alcoholic.” We tend to ignore excessive drinking in people that seem functional. If a patient looks and behaves “normally,” doctors may fail to probe with questions about their drinking behavior. Also, because doctors are used to “addiction” being associated with severe cases, they may not think to look for signs of alcohol misuse in patients who have not been labeled as an alcoholic.
Finally, some doctors suffer the same misconception as the rest of us: if you want to stop drinking, you just go to AA. Poorman argues that even brief counseling by a doctor or prescriptions of medication that reduce heavy drinking can help immensely, perhaps even making the difference between life and death for some patients. But doctors are under pressure to keep visits short and see as many patients as possible; under this stress, it’s easy to avoid questions that might throw them off schedule.
Which Alcohol Screenings Should I Use?
Several screenings have stood the test of time: CAGE, MAST, and AUDIT. CAGE is a short, simple questionnaire often used in primary settings; it is useful in detecting a range of alcohol misuse. Longer tests, such MAST (Michigan Alcoholism Screening Test) or AUDIT (Alcohol Use Disorders Identification Test), can be used when more qualitative information is needed.
Clinicians interested in learning more about screenings and intervention can consult this guide for clinicians that provides tips on how to counsel patients who may be drinking too much. Also, at least for now, the Affordable Care Act requires new health insurance plans to cover alcohol screening and brief intervention (ASBI) without a copayment.
What is the Most Efficient Way to Conduct Screenings?
As useful as these screenings are, they take time. In a typical 15-minute visit, clinicians are hard-pressed to provide any screening, much less counseling, that goes beyond the issues at hand. What can doctors do to save time while still providing this important service to their patients?
Here are several time-saving suggestions, per the advice of the NIAAA and Dr. Frieden:
- Just one simple question can accurately identify patients who meet NIAAA criteria for at-risk drinking or DSM-IV criteria for alcohol dependence: “On any single occasion during the past 3 months, have you had more than 5 drinks containing alcohol?” If the patient answers “yes” to this question, the clinician can proceed with more qualitative screening.
- Alcoholism screening questions can be included on patient history forms. Depending on the patient’s answers, clinicians can decide whether counseling is necessary.
- Counseling interventions can be brief (6-15 minutes) and do not have to be conducted by the clinician. Other health professionals such as nurses, social workers, and psychologists can share the responsibility.
- Both screening and counseling can be provided electronically.
What if my patient lies about his or her drinking habits?
According to a 2015 study, about 1 in every 4 patients (30% of women; 23% of men) lies or omits information when consulting with their doctor. Patients lie or omit information for many reasons: embarrassment or fear of being judged (42%), not wanting to take up a doctor’s time (27%), and because doctors didn’t specifically ask about a symptom (32%).
Patients may feel especially fearful of admitting heavy drinking habits because they don’t want to be labeled—and because they don’t want to change their habits.
What can you do if you suspect your patient is lying?*:
- Confront them without being judgmental. Understand that their dishonesty is probably due, in large part, to fear. Be empathetic.
- Explain the consequences of alcohol misuse. Make sure patients understand the difference between alcohol dependence and misuse and that alcohol, even in amounts most would consider manageable, can have negative health effects.
- Assure the patient that your conversation and diagnosis will be confidential.
In conclusion, we encourage clinicians and health care practitioners to take advantage of their one-to-one relationship with their patients and to learn more about screening and counseling for alcohol misuse or dependence.
For patients who need extensive treatment, resources are available. Medication, addiction counseling, AA meetings, outpatient programs, and residential treatment provide different levels of care to help patients recover and sustain good health.
*tips taken from When Patients Lie to You. Roswell Park Cancer Institute.