Alcohol screening in primary care increased initial treatment but not longer-term engagement

An intervention resulted in increased alcohol screening, brief preventive counseling, new diagnosis of alcohol use disorders, and initiation of treatment, although it did not increase engagement in treatment compared with usual primary care, a study found.

The Sustained Patient-Centered Alcohol-Related Care trial was conducted in 22 primary care practices in an integrated health system in Washington state. Participants (n=333,596) included all adult patients with primary care visits in January 2015 to July 2018. Using practice facilitation, decision support, and performance feedback, the trial aimed to have clinicians annually screen all patients for alcohol use disorder (AUD), providing a brief intervention for patients who screened positive, and for those with high-risk drinking, engaging in shared decision-making about AUD treatment and supporting initiation. Results were published by JAMA Internal Medicine on Feb. 27.

The proportion of patients who received a brief intervention was higher during the intervention than during usual care periods (57 vs. 11 per 10,000 patients per month; P<0.001). The intervention increased intermediate outcomes: screening (83.2% vs. 20.8%; P<0.001), new AUD diagnosis (33.8 vs. 28.8 per 10,000 patients per month; P=0.003), and initiation of treatment (7.8 vs. 6.2 per 10,000 patients per month; P=0.04). However, the rate of engagement in AUD treatment, which the study defined as two more visits with alcohol or drug ICD-9/ICD-10 codes within 30 days following initiation, was not different between the intervention and usual care groups (1.4 vs. 1.8 per 10,000 patients per month; P=0.30).

The study authors noted that while the trial succeeded in increasing systematic screening and brief intervention, as well as assessment of symptoms, new diagnoses, and treatment initiation, “the magnitude of increases in brief intervention and AUD treatment initiation were modest, and AUD treatment engagement was not increased. Given the extent of the gaps in the quality of alcohol-related care, iterative quality improvement efforts will likely be needed.”

An editorial said that the effect of increased screening and identification of unhealthy alcohol use and the opportunity for brief counseling can be profound. “Unhealthy alcohol use is not a moral weakness; it is a modifiable risk factor, self-medication for mental distress, or addiction that clinicians and patients need to address together,” the editorial concluded. “Although treatment options for people with more severe AUD are more limited in their efficacy, brief counseling interventions, provided in the primary care setting, can help patients with risky and hazardous drinking to drink less. Clinicians and patients should feel comfortable talking about and documenting alcohol use objectively and without judgment.”

A cover story in the March ACP Internist discusses ways to increase alcohol screening and counseling in primary care.