The patient was a 29-year-old male who said he constantly "feels drowsy," especially the last 3 weeks. I considered differentials as I took his history, such as seasonal allergies, adverse reactions from medications, sleep disorder, stress, depression, and drug/alcohol use. His depression screen was positive, and he agreed that he might be a little depressed. He also admitted that he had significantly decreased his use of street drugs (types and frequency) along with alcohol 3 weeks ago. He now only used marijuana; however, he stated he consumes 6 to 10 alcoholic drinks every night and more on occasions when he plays music with his band. Last year, his behaviors started to affect his performance at work, so at the suggestion of his boss, he sought counseling through the Employee Assistance Program. Therapy helped, but he stopped after 2 months once his mood improved.
Hazardous drinking
In May, the United States Preventive Services Task Force (USPSTF) issued new guidelines for screening and intervention in primary care for alcohol misuse. The USPSTF defines alcohol misuse as "a spectrum of behaviors, including risky or hazardous alcohol use (for example, harmful alcohol use and alcohol abuse or dependence). Risky or hazardous alcohol use means drinking more than the recommended daily, weekly, or per-occasion amounts, resulting in increased risk for health consequences."1 Clinicians are encouraged to "screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse."2 These recommendations were made based on the high certainty that the net benefit of this screening and intervention in primary care is moderate (Grade B Recommendation).2 Evidence for screening adolescents was insufficient for the same recommendation based on benefits versus harm.
Alcohol screening test
The National Institute on Alcohol Abuse and Alcoholism cites statistics for American adults 18 years and older who had at least one drink in the past year at 59.6% for women and 71.8% for men, and for adults who consumed three or more drinks per day at21.9% for women and 42.3% for men.3 Healthcare professionals (HCP) must ask very specific questions about alcohol use. The USPSTF suggests using a valid and reliable screening tool andindicates that the Alcohol Use Disorders Identification Test, developed by the World Health Organization, has been the most widely studied instrument for detecting alcohol misuse in primary care. It contains 10questions, takes only 2 to 5 minutes to administer, and has been used with multiple populations and cultural groups.4 Many other screening tools are also available.
Behavioral counseling
Identifying unhealthy alcohol use dictates some intervention on the HCP's part. Evidence demonstrated that multiple brief behavioral counseling contacts were more effective than brief behavioral counseling. The USPSTF defines intervention intensity as very brief single contact (5 minutes or less), brief single contact (6 to 15 minutes), brief multicontact (each contact is 6 to 15 minutes), and extended multicontact (1 contact or more, each more than 15 minutes).2 Contact can be in-person, through written materials or computer/web-based programs, or by phone, and can include a number of cognitive behavioral strategies, such as stress management or keeping a diary of drinking habits. The report did not look at other interventions, such as pharmacotherapy or outpatient treatment programs. The goal is to help patients reduce risky behaviors by decreasing and sustaining alcohol consumption to recommended amounts.
Jamesetta Newland, PhD, RN, FNP-BC, FAANP, FNAP
EDITOR-IN-CHIEF [email protected]
REFERENCES