Questioning the quantity and frequency of alcohol use was the most common screening approach reported, with 80% of respondents indicating they “always” asked these questions. CAGE questions were either “frequently” or “always” used by only 35% of survey physicians. CAGE was “never” used by 27% of respondents, while MAST and DSM-IV criteria were not used by 83% and 75%, respectively. No physicians reported using AUDIT when asked to name approaches not listed in the survey. Laboratory markers were either “frequently” or “always” used by 57% of the physicians.
Only a small proportion of respondents cited time constraints and intrusiveness as barriers to alcohol screening Table 1. Thirty-five percent responded that inadequate resources were available for the treatment of alcohol-dependent patients, and more than half (53%) believed treatment resources were inadequate for the early problem drinker. Most respondents (90%) replied that an intervention by a primary care physician concerning alcohol abuse or dependence could have a positive impact on such behavior, but only 21% were willing to say that treatment would be successful for at least half of these patients. Regarding the preferred type of intervention for early problem drinkers, 28% of surveyed physicians preferred personally counseling the patient in two 10- to 15-minute sessions, consistent with the approach recommended by Fleming and colleagues.15 The remaining respondents (72%) favored referring the patient to a nurse trained in behavioral interventions.
Discussion
This survey was conducted 3 years after publication of the NIAAA guidelines for the screening and treatment of problem drinkers in primary care practices.9 Only two thirds of the 131 primary care physicians responding to our survey reported that they screened nearly all of their patients for alcohol problems during the initial visit, and one third screened nearly all their patients during annual visits. Wenrich and coworkers16 similarly found that approximately one half of 134 primary care physicians asked an alcohol-screening question of the majority of standardized patients. Our survey results also indicate that if screening does not occur during the initial visit, it is unlikely to occur at another time in the longitudinal provider-patient relationship.
Although alcohol quantity and frequency of use questions appear to be the mainstay for screening by our respondents, concerns have been raised in the medical literature about the reliability of using this approach alone.17,18 Patient denial of alcohol use and memory problems have been blamed for self-report underestimations of alcohol consumption by 40% to 60% in one region of the country.17 Several studies have found that physicians accept a higher rate of consumption as normal than would NIAAA experts.16,19 Due in part to these concerns, NIAAA recommends a second screening step of asking CAGE questions of all current drinkers. However, nearly two thirds of our respondents reported that they either do not ask CAGE questions or ask them only occasionally. Since at least 60% of Pennsylvania residents consume alcohol according to a 1995 NIAAA surveillance report,20 and current drinkers visit primary care settings more often than nondrinkers,21 our data indicate that many respondents were not screening current drinkers with the CAGE questions. Studies preceding the publication of the NIAAA guidelines also indicate that the CAGE questionnaire is rarely used by primary care clinicians.16,19 Further, our respondents rarely reported using another screening tool in lieu of CAGE even though other approaches, such as TWEAK (Tolerance, Worried, Eye-openers, Amnesia, Cut down) and the Alcohol Use Disorders Identification Test (AUDIT) may outperform the CAGE questionnaire in certain primary care patient populations.22,23
Laboratory tests suggestive of problem drinking (eg, gamma glutamyltransferase, aspartate aminotransferase, and erythrocyte mean cell volume) were used “most of the time” by more than half of our respondents. Although such markers may provide clues to the diagnosis of alcohol abuse, no test or combination of tests is as useful as the CAGE or MAST questionnaire in diagnosing alcohol abuse.24,25 The NIAAA suggests that laboratory markers could be useful in assessing compliance with an alcohol treatment plan but does not recommend their use for detecting problem drinking.9
Few respondents felt that time constraints or intrusive questions presented obstacles to screening. Yet once a patient was identified as a problem drinker, many respondents were dissatisfied with the availability of resources for treatment, especially for early problem drinking. Many were also skeptical about the success of such treatment. Optimism was greater regarding the positive impact of an intervention by a primary care physician for patients who abuse or are dependent on alcohol. This belief is consistent with the results of a randomized controlled trial by Fleming and colleagues15 of several short primary care physician-conducted sessions on alcohol use. However, nearly three fourths of our survey physicians favored referring a problem drinker to a nurse trained in behavioral interventions. A study of a nurse-conducted behavioral program for problem drinkers found that 80% of primary care physicians in a Canadian city willingly referred their patients with drinking problems to the program.26 This program led to a significant reduction in alcohol consumption.