Brief alcohol screening misses mark for people who most need help, study says

As screening for alcohol problems during doctor visits has become more mainstream, a new study published in the journal Addiction finds that the technique does not increase successful referrals to alcohol counseling and treatment.

Screening has been promoted for decades because only 6 percent of people who struggle with alcohol seek help in any year, says study author Joseph Glass, assistant professor of social work at the University of Wisconsin–Madison and an expert on alcohol addiction and treatment. “That’s mainly because they don’t think they need help at all.”

Doctors, Glass says, “have been encouraged to use basic conversational techniques, to spend five or 10 minutes to ask about drinking and talk about ways they could reduce it.”

The process is called screening and brief intervention, or screening, brief intervention and referral to treatment.

Studies have found that it helps people with milder drinking problems reduce their consumption. But when Glass and colleagues summarized existing randomized, controlled trials that tracked almost 2,000 people, they found no increase in the number of people who sought counseling or treatment — a result that surprised them. “We expected to see some benefits, but there was no difference in the number of people who got care between those who got the screening and brief intervention and (those) who did not.”

Unhealthy alcohol use is the third leading cause of death in the United States, Glass and his colleagues wrote, costing the nation more than an estimated $230 billion each year. About 17.6 million American adults have alcohol use disorder, defined as drinking that has become excessive enough to cause problems in one’s life.

For decades, social scientists have realized that most people don’t want to start alcohol treatment, Glass says. “In response, in the late 1980s, the thought was, ‘If nobody is going to go find care, let’s bring it to them.'”

Soon after, a referral component was added to the screening, and Wisconsin became a leader in making alcohol screening a routine component of doctor visits.

The study did not explain why screening and brief intervention does not produce the desired successful referrals, Glass says. It may be helpful to involve counselors, “or we may need to have multiple conversations over a period of time,” he says, on the theory that familiarity will build essential trust.

Screening along with other efforts to get more people treated for depression have proven highly effective, Glass says, and so the lack of referrals in the present study may be related to the stigma linked to excess alcohol consumption.

A brief alcohol screening might start with a simple question, Glass says. “‘Now I want to ask about drinking: How many times in the past year have you had five or more drinks in one sitting?’ If you said zero, I usually don’t need to follow up. If you said more, I would continue: ‘What are some of the biggest downsides of your drinking?’ that gives me an idea where the conversation should go. I might discuss how drinking may exacerbate health problems, trying to build up the momentum of the conversation.”

In other studies, screening and brief intervention has been associated with a reduction in drinking, Glass says. “It’s a great, cost-effective intervention for people with mild problems, but it isn’t working for people with more severe problems. This is definitely a practice that should happen, but we need to acknowledge it does not help everybody and so we need to find out how to reach people with the most severe alcohol problems … Given the social, personal and economic costs of alcohol addiction, it’s vital that we figure out what would work.”