[Skip to Content]
[Skip to Content Landing]
Invited Commentary
Substance Use and Addiction
May 13, 2020

Clinical Utility of Routine Alcohol Screening in Large Health Care Systems for Addressing a Leading Epidemic in the US

Author Affiliations
  • 1Department of Health Services, University of Washington School of Public Health, Seattle
  • 2Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
JAMA Netw Open. 2020;3(5):e204757. doi:10.1001/jamanetworkopen.2020.4757

The study by Sterling et al1 in this issue of JAMA Network Open used electronic health record–documented alcohol screening data from nearly 3 million patients receiving care at Kaiser Permanente Northern California to assess cross-sectional associations between 26 medical conditions and levels of alcohol use. The authors found that not drinking alcohol was generally more common among patients with medical conditions than among those without (likely reflecting abstinence owing to poor health). In adjusted analyses among patients reporting any alcohol use, those with chronic liver disease, chronic obstructive pulmonary disease, hypertension, and diabetes were more likely than those without to report patterns of unhealthy alcohol use. This is concerning because these conditions contribute substantially to the burden of morbidity and mortality in the US and are exacerbated by alcohol use.2 Unadjusted analyses suggest the possibility of even greater alcohol-related health burden in this population. Patients with 10 conditions associated with alcohol use (arthritis, atherosclerosis, atrial fibrillation, cancer, chronic obstructive pulmonary disease, coronary artery disease, gastroesophageal reflux, hyperlipidemia, hypertension, osteoarthritis, and osteoporosis and osteopenia) were disproportionately overrepresented in the group of patients reporting exceeding weekly alcohol consumption limits (2.7%-4.0% vs 2.4% in the population). Patients with HIV infection, a population for whom the risks of alcohol use are substantial, were underrepresented in the nondrinking group (64.6% vs 68.3% in the population) and reported exceeding daily alcohol consumption limits at equivalent levels as the general patient population (6.3% vs 6.1% in the population).

Globally, alcohol use is the seventh leading risk factor for death and disability and the leading risk factor within younger age groups.3 Alcohol use is also a leading risk factor for preventable morbidity and mortality in the US, where data from the 2018 National Survey on Drug Use and Health suggest that 70% of the population consumes alcohol and 14.4 million people have an alcohol use disorder (7 times the number with opioid use disorder). The past 2 decades have been marked with steep increases in alcohol consumption, especially for some subgroups (eg, women and younger adults), which has contributed to lower overall life expectancy associated with increased alcohol-related liver disease mortality and other epidemics influenced by alcohol consumption (eg, suicide and drug overdose).2,4 Simultaneously, notions that low levels of alcohol use may have protective effects for some conditions have been credibly disputed by studies applying advanced methods to account for study characteristics known to bias results,5 and some studies suggest that the only level of alcohol use associated with no harm is no use.3

Despite the substantial and growing burden of alcohol-related harm in the US and the availability of evidence-based interventions and treatments to help people stop or reduce their alcohol use, alcohol use remains under-addressed in clinical settings. However, information on patients’ alcohol consumption is increasingly available in large health care systems. As Sterling et al1 highlight, since implementation of population-based alcohol screening in Kaiser Permanente Northern California, over 12 million alcohol screenings have been conducted in over 150 clinics, with screening capturing alcohol use in the majority (87%) of the patient population annually. Similarly, the national Veterans Health Administration screens approximately 90% of all outpatients for unhealthy alcohol use annually, resulting in more than 40 million documented screenings in the past 10 years. Other large health care systems (eg, Kaiser Permanente Washington) have similarly integrated routine alcohol screening for all patients, and large recent investments by the Department of Health and Human Services and Agency for Healthcare Research and Quality will result in greater frequency of alcohol screening in health care systems across the US.6

Although policy and other macro-level solutions will likely be necessary to combat the increasing burden of alcohol use in the US, capitalizing on information obtained from routine alcohol screening to improve clinical care could represent a stronghold in addressing this growing public health crisis. Specifically, as demonstrated in the unadjusted analyses by Sterling et al,1 this information may help clinicians understand the prevalence of any alcohol use and unhealthy alcohol use in key clinical subpopulations at increased risk of alcohol-related harm. This information also enables monitoring changes in patients’ alcohol use over time, especially for patients for whom the risks associated with alcohol use are elevated (eg, those with chronic liver conditions), and could be used to generate and monitor outcomes of targeted interventions.

Finally, population-based alcohol screening is considered the sin qua non for provision of recommended evidence-based alcohol-related care aimed at reducing alcohol consumption and alcohol-related harm: evidence-based brief intervention for unhealthy alcohol use and/or behavioral or medication treatment for alcohol use disorder.7,8 Alcohol screening information collected in routine clinical care can be used to support and monitor outcomes after provision of recommended care. For instance, alcohol screening results can be used, as they have been in the Veterans Health Administration, to understand levels of use at which risks for subsequent medical outcomes increase9 and whether changes in reported alcohol use over time are associated with concomitant changes in medical outcomes.10 This information, in turn, could be incorporated into clinical information systems to support providers in offering repeated brief interventions so that providers can directly assess the association between patients’ alcohol use and their health risks and help patients understand the benefits of reducing and/or abstaining from alcohol use, as well as to track outcomes after provision of medications and behavioral treatments.

Data such as those presented by Sterling et al1 highlight the wealth of information that can be offered to providers on patients’ alcohol consumption over time in health care systems with population-based screening. Clinicians and health care systems should capitalize on this resource to improve the quality of alcohol-related care and combat the large and increasing threat of alcohol use in the US.

Back to top
Article Information

Published: May 13, 2020. doi:10.1001/jamanetworkopen.2020.4757

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Williams EC. JAMA Network Open.

Corresponding Author: Emily C. Williams, PhD, MPH; Department of Health Services, University of Washington School of Public Health, Box 357660, Seattle, WA 98195 (emily.williams3@va.gov).

Conflict of Interest Disclosures: None reported.

References
1.
Sterling  SA, Palzes  VA, Lu  Y,  et al.  Associations between medical conditions and alcohol consumption levels in an adult primary care population.   JAMA Netw Open. 2020;3(5):e204687. doi:10.1001/jamanetworkopen.2020.4687Google Scholar
2.
Woolf  SH, Schoomaker  H.  Life expectancy and mortality rates in the United States, 1959-2017.   JAMA. 2019;322(20):1996-2016. doi:10.1001/jama.2019.16932PubMedGoogle ScholarCrossref
3.
GBD 2016 Alcohol Collaborators.  Alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.   Lancet. 2018;392(10152):1015-1035. doi:10.1016/S0140-6736(18)31310-2PubMedGoogle ScholarCrossref
4.
White  AM, Castle  IP, Hingson  RW, Powell  PA.  Using death certificates to explore changes in alcohol-related mortality in the United States, 1999 to 2017.   Alcohol Clin Exp Res. 2020;44(1):178-187. doi:10.1111/acer.14239PubMedGoogle ScholarCrossref
5.
Stockwell  T, Zhao  J, Panwar  S, Roemer  A, Naimi  T, Chikritzhs  T.  Do “moderate” drinkers have reduced mortality risk? a systematic review and meta-analysis of alcohol consumption and all-cause mortality.   J Stud Alcohol Drugs. 2016;77(2):185-198. doi:10.15288/jsad.2016.77.185PubMedGoogle ScholarCrossref
6.
US Department of Health and Human Services, Agency for Healthcare Research and Quality. Initiative to reduce unhealthy alcohol use. Accessed X. https://integrationacademy.ahrq.gov/about/opioids-substance-use/ahrq-alcohol-initiative
7.
Jonas  DE, Garbutt  JC, Amick  HR,  et al.  Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force.   Ann Intern Med. 2012;157(9):645-654. doi:10.7326/0003-4819-157-9-201211060-00544PubMedGoogle ScholarCrossref
8.
Jonas  DE, Amick  HR, Feltner  C,  et al.  Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis.   JAMA. 2014;311(18):1889-1900. doi:10.1001/jama.2014.3628PubMedGoogle ScholarCrossref
9.
Bradley  KA, Rubinsky  AD, Lapham  GT,  et al.  Predictive validity of clinical AUDIT-C alcohol screening scores and changes in scores for three objective alcohol-related outcomes in a Veterans Affairs population.   Addiction. 2016;111(11):1975-1984. doi:10.1111/add.13505PubMedGoogle ScholarCrossref
10.
Rubinsky  AD, Chavez  LJ, Berger  D,  et al.  Utility of routine alcohol screening for monitoring changes in alcohol consumption.   Drug Alcohol Depend. 2019;201:155-160. doi:10.1016/j.drugalcdep.2019.03.010PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    ×