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Alcohol Awareness: Affordable Care Act Facilitates Screening

If people you care about drink too much, encourage them to seek medical help.
Lance Dodes, M.D.
This post is a response to The Sober Truth About AA and the Rehab Industry by Lance Dodes, M.D.

© 2005 by Tomasz Sienicki (Creative Commons)
Here is at least one reason that those for and against the Affordable Care Act can find a reason to unite in gratitude. National Alcoholism Screening Day is April 10 and the Centers for Disease Control and Prevention pointed out that an ACA requirment is that new health insurance plans cover this service without a co-payment.

Alcohol abuse and alcoholism can take a devastating toll on individuals and families at a $224 billion cost to the US economy. Physicians have been advocating for screening and models have been developed for screening in offices and in emergency departments. 

The CDC tells us that at least 38 million adults – although not considered alcoholics – are drinking too much; that is, binge drinking, drinking too much weekly, using alcohol in pregnancy and underage drinking.

I was reminded to look at medical resources after reading: The Sober Truth About AA and the Rehab Industry by Lance Dodes, MD, at Harvard.

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Alcoholism and pregnancy

With approximately 5,000 infants born each year with fetal alcohol syndrome in the United States, heightened awareness is key. Peter D. Friedmann, MD, MPH, is professor health services, policy and practice at BrownUniversity’s Center for Alcoholism and Substance Abuse:  He says: “During the first trimester any alcohol consumption is concerning.” As such, it is important for a physician to ask when the woman had her last drink.

Dr. Friedmann pointed out in “Alcohol Use in Adults,” published in a 2013 issue of the New England Journal of Medicine, “Clinicians should routinely screen patients for risk drinking and further discuss management strategies.” (1)

Dr. Gail D’Onorfio at Yale presented a seven minute intervention model to be used for screening in the Emergency Department. (2)

Pregnancy intervention

With pregnancy, in an earlier interview Dr. Friedmann explained,  “During the first trimester any alcohol consumption is concerning.” As such, it is important for a physician to ask when the woman had her last drink.

Dr. Friedmann pointed out in “Alcohol Use in Adults,” published in a January issue of the New England Journal of Medicine, “Clinicians should routinely screen patients for risk drinking and further discuss management strategies.”  (1)

There are two tests that clinicians might use to assess drinking in pregnant women. T-ACE is a measurement tool of four questions that are significant identifiers of risk drinking (i.e., alcohol intake sufficient to potentially damage the embryo or fetus), devised by Robert J. Sokol. T-ACE stands for Tolerance, Annoyance, Cut Down, and Eye-Opener.

A similar test called TWEAK stands for Tolerance, Worried, Eye-Opener, Amnesia, K-Cut down.

In both tests, the short questionnaires essentially try to determine alcohol consumption, including how many drinks it takes to get high. Annoyance felt when friends express worry about your drinking. And drinking first thing in the morning as an eye-opener. Forgetting what happened during drinking (amnesia) is a serious concern. And both questionnaires ask: Do you think you should cut down?

Based on the results, a clinician will make recommendations for intervention, which often includes counseling.

Seven minute intervention in the ER

A Yale study, recently published in the Annals of Emergency Medicine, says that seven minutes of emergency room intervention might alleviate the problem of alcoholism.

Researchers randomized 889 adult patients in the emergency department (ED) who had symptoms of hazardous and harmful drinking. Dr. Gail D’Onofrio, Chief of the Emergency Department atYale-New HavenHospital, explained a simple intervention, “a conversation to help motivate the patient to change” called a Brief Negotiation Interview (BNI). She said “The first step is a practitioner asking, ‘Would you mind if I talk with you about your alcohol use?’ — then saying, ‘I’m concerned about your risk for illness or injury.’ ”

She added: “We try to make a connection between a health issue and the binge drinking whether hypertension, a sexually transmitted disease, or a car crash.” The goal is to heighten awareness “between their drinking and how it is that they ended up in the ED.”

What happens next is “the hard part.”  D’Onofrio said: “The physician tries to motivate the patient to reduce drinking into low risk limits by asking: ‘On a scale from 1 to 10 how ready are you to change your drinking?’

After the patient chooses a number, the next question might be: ‘Why did you not choose a lower number?’ This starts a conversation as to why the patient would want to make a change. After some reflection we try to negotiate a number that the patient can agree to by asking ‘So, how much do you think you can reduce drinking?’ ”

Once the patient agrees to a number he or she is encouraged to write it down. “In this way it becomes a contract,” she said. “Then we thank them for their time.”

For part of the sample, a nurse will make a booster call one month later in addition to the intervention. Motivating patient change: Brief Negotiation Interview, Dr. D'Onofrio

D’Onofrio noted, “We spend more valuable minutes with ED patients talking about tetanus — which most of us have never seen — than we do screening and intervening with hazardous and harmful drinkers who flood the ED. We need to normalize the process of screening and intervention for alcohol problems. This will be a giant step toward improving the health of the public.”

A challenging problem

In Measuring the Burden — Alcohol's Evolving Impact  editors Ralph Hingson, Sc.D., and Jürgen Rehm, Ph.D.point out:

Numerous challenges exist when measuring the extent and predictors of alcohol-related mortality and morbidity. Those challenges also affect our ability to evaluate the effectiveness of interventions to reduce alcohol-related morbidity and mortality. Editors’ Note (3)

It seems that both screening and developing patient-physician partnerships may yield some valuable interventions. Although researchers and the CDC have found that  “screening and brief counseling can reduce drinking on an occasion by 25% in people who drink too much, but only 1 in 6 people has ever talked with their doctor or other health professional about alcohol use.”

April may be the time for those concerned about drinking to talk to physicians and health care practitioners about alcohol consumption, which causes about 88,000 deaths yearly.(4)

References:

1. Peter D. Friedmann, M.D., M.P.H. / N EnglJ Med 2013; 368:365-373 January 24, 2013 DOI: 10.1056/NEJMcp1204714

2. D’Onofrio G, et al. A Brief Intervention Reduces Hazardous and Harmful Drinking in Emergency Department Patients. Ann Emerg Med.2012;60:181-192.

3.  Ralph Hingson, Sc.D., and Jürgen Rehm, Ph.D.,  Measuring the Burden: Alcohol’s Evolving Impact Alcohol Research: Current Reviews, Volume 35, Issue Number 2

4. CDC - Alcohol Screening and Counseling | Vital Signs 

Copyright 2014 Rita Watson

Rita Watson is an Associate Fellow at Yale's Ezra Stiles College and a columnist for The Providence Journal.

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