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Editorial
November 13, 2018

Unhealthy Alcohol Use in Primary Care—The Elephant in the Examination Room

Author Affiliations
  • 1Yale School of Medicine, New Haven, Connecticut
  • 2Yale School of Public Health, New Haven, Connecticut
JAMA Intern Med. Published online November 13, 2018. doi:10.1001/jamainternmed.2018.6125

Unhealthy alcohol use is a serious public health challenge that requires full attention.1 In its recommendation statement,2 supported by an evidence report and systematic review,3 the US Preventive Services Task Force (USPSTF) “recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use (B recommendation).”2 One in 8 adults in the United States reports unhealthy alcohol use.4 Unhealthy alcohol use includes “at-risk” alcohol use, defined by the National Institute on Alcohol Abuse and Alcoholism as alcohol use greater than 4 drinks per occasion or 14 drinks per week for men aged 21 to 64 years and 3 drinks per occasion or 7 drinks per week for women of all ages and for men 65 years or older. It also includes alcohol use disorder, defined by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) based on the presence of 2 or more of 11 criteria, such as loss of control of use and withdrawal symptoms.4 About 6% of US adults have drinking patterns and associated symptoms that are sufficiently severe to meet criteria for alcohol use disorder. Globally, 1 in 20 deaths are related to alcohol use.1

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    2 Comments for this article
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    Need to always ask about alcohol use
    Phillip Shepard, MD | Retired Family Physician
    During years of practice hardly a day went by when I didn't see a patient with an alcohol related problem or a family member affected by alcoholism in the home. Once I delivered a small baby with the abnormal physical features. He had Fetal Alcohol Syndrome. When questioned the mother gave a history of significant alcohol use during pregnancy. Many women are "hidden alcoholics". I worked in the Pathology Department as a student. The pathologist diagnosed a case of alcoholic liver disease as cause of death at autopsy of a woman who denied drinking. Only after our post mortem diagnosis did the family members admit that "Mom drank a lot". Drinking patterns vary. Some problem drinkers can go for months without drinking but then go on a "bender" and end up losing their job or dying in an auto accident. Some young males have the hereditary form of "the violent alcoholic": rapid addiction, blackouts, violent behavior as described by Jellinek. The middle-aged woman with rash on her legs and abnormal liver functions due to a diet heavy on wine, low on vitamins. In addition to seeking out the correct diagnosis the long-term management always looms over us. All areas of medicine are affected and all doctors need to adopt the USPSTF recommendations.
    CONFLICT OF INTEREST: None Reported
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    A single question about drinking that is empirically validated as a screening
    Reid Hester, Research Division | CheckUp & Choices
    How many times in the last 12 months have you had 5 or more (4 or more for women) drinks on one occasion. An answer of 1 or more is a positive screen. This screening question can easily be embedded into a lifestyle screening that also asks about diet, exercise, smoking, sleeping, etc.

    Physicians, PAs or Medical Assistants can then give brief feedback and recommend the patient get a more detailed assessment like our alcohol CheckUp on www.checkupandchoices.com.
    CONFLICT OF INTEREST: I am a co-founder of CheckUp & Choices that disseminates digital tools for people with alcohol and drug misuse.
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