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FACCT places focus on addressing alcohol misuse
Smoking, poor diet, and lack of exercise top the list of bad habits that physicians counsel their patients to alter. But another risky behavior may not be getting enough attention: excessive drinking.
While only about 5% of Americans could be called alcoholics, another 20% are "risky drinkers" who exceed recommended limits at least once a year, says John Higgins-Biddle, PhD, assistant professor at the University of Connecticut School of Medicine in Farmington and a specialist in alcohol research.
The impact of alcohol misuse is pervasive, including loss of work productivity, automobile accidents, strain on family relationships, and direct health effects. Yet even brief counseling by physicians can influence patients to moderate their use of alcohol, he says.
While alcoholics need specialized treatment to help them control their dependency, people who misuse alcohol may not even realize that they have stepped beyond moderate levels, he says. "Most people who are at-risk drinkers can reduce their drinking to or close to safe levels with three to five minutes of simple advice."
Some health plans may begin monitoring whether providers are screening and counseling patients on alcohol consumption. That’s the goal of a measurement set recently released by the Foundation for Accountability (FACCT) in Portland, OR. FACCT developed a patient survey tool that health plans and medical groups could use to learn whether providers are asking about alcohol use and providing adequate information.
"It’s very much a priority of the purchasers and consumers on our board," says Christina Bethell, PhD, MBA, MPH, director of accountability measurement for FAACT. "When you look at the relationship between alcohol misuse and complications related to health, family, work, domestic violence, and on and on, you can understand why it’s an important problem. "We’re hoping this measurement set will stimulate interest and activity in this area," she says. "It’s been well-documented that the need is great."
Bouts of drinking among people who aren’t actually addicted to alcohol contribute heavily to both health and societal costs. A 1990 Institute of Medicine report stated that "a principal focus of intervention should be on persons with mild or moderate alcohol problems."1 The World Health Organization in Geneva coined the term "alcohol misuse" to incorporate this broader population.
"The issue here is not addiction. The issue is consumption," says Higgins-Biddle. "If you consume too much alcohol, you’re at risk, whether you’re addicted or not."
As a first step, physicians need to be educated about the alcohol use guidelines and the dangers of misuse, says Higgins-Biddle.
The U.S. Dietary Guidelines recommend no more than one drink a day for women and two drinks a day for men. Yet Higgins-Biddle emphasizes that he isn’t targeting the person who drinks excessively one time.
"What we want to do is to identify the people who have a significant risk," he says. "It’s not cost-effective to find that person who one day two years ago had three drinks.
"This is not neo-prohibition," he says. "We’re not trying to say people shouldn’t drink at all."
Counseling needs to be targeted toward those occasionally or often misuse alcohol, who can benefit most. So Higgins-Biddle and colleagues use a screening tool to detect levels of alcohol misuse among primary care patients. FACCT has also incorporated this tool in its measurement set. (See copy of the tool, p. 69.)
He is testing a screening and brief intervention program called "Cutting Back" in primary care settings, and he says preliminary results show that it can significantly reduce alcohol misuse.
The screening tool, which is completed by the patient, is brief and easy to score; it contains only 10 questions. Effective interventions need only take about three minutes, says Higgins-Biddle.
Interventions begin with feedback to patients about how they scored on the screening tool and information about appropriate drinking. For example, a physician may begin by saying, "I’d like to talk to you about your drinking since the answers on the screen showed your drinking is likely to present risks to your health. Are these answers correct?"
The physician would then describe the health consequences, such as gastrointestinal problems, which can be related to overuse of alcohol. The safe limits of the dietary guidelines also should be clearly communicated.
"Solicit a commitment to either cut back or stop," advises Higgins-Biddle. "It’s important for patients to be put in a situation where they have to make a decision based on the doctor’s or nurse’s advice. What would you like to do about this? To do nothing is not a wise choice in light of the health risks.’"
The physician also may talk with the patient about what influences the drinking — such as certain social settings — as a way to help patients find ways to cut back. Patients respond well to a program of brief intervention, and they tend to speak honestly about their drinking habits, he says.
"Patients know doctors need to know these things to provide good health care," he says. "Almost all of them are happy to provide this information and grateful for the advice."
4. While only about 5% of Americans could be called alcoholics, how many are risky drinkers who misuse
alcohol at least once a year?