Vital Signs: Alcohol Screening and Counseling

OPERATOR: Welcome, and thank you for standing by. At this time all participants will be in a listen only mode. After the presentation we'll conduct a question and answer session. To ask your question, please press star 1. Today's conference is being recorded. If you have any objections you may disconnect at this time. I will now turn the meeting over to Mr. Tom Skinner. You may begin.

TOM SKINNER: Thanks, Christi, and thank you all for joining us for the release of another CDC Vital Signs, the first of 2014, this one on communication between health professionals and their patients when it comes to alcohol use in 44 states and the District of Columbia, 2011. With us today is the director of the CDC, Dr. Tom Frieden who will provide some opening remarks, and then we will move to your questions. So, Dr. Frieden?

TOM FRIEDEN: Thanks very much for joining us today for this month's Vital Signs report. Every month we focus on the latest data about one critical health issue facing the country and what we know can be done about it. This month we're addressing communication about alcohol use between health professionals and their patients. Drinking too much causes about 88,000 deaths a year in the U.S. and costs our economy more than $220 billion. It also causes a very wide range of health, social, and other problems. Ranging from injury to damage to the liver and heart and nerves, to depression and violence, to problems with personal and social life to motor vehicle crashes, hypertension and heart attacks, fetal alcohol syndrome, sudden alcohol-- sudden infant death syndrome, and sexually transmitted diseases from behavior that would not have occurred without problem drinking. So, drinking is a serious problem for many people and, in fact, at least 38 million adults in the U.S. drink too much. Now, one thing that many people may not recognize is that the vast majority of those individuals are not alcoholic. In fact, for every one person who is alcoholic, there are about six who are problem drinkers, drinking enough to adversely affect their lives, their health, their work situation or family situation, but who are not alcoholic. Drinking too much includes binge drinking, high average drinking, and any alcohol consumed by pregnant women and people under the age of 21, as well as people who are drinking and driving or operating heavy machinery. People often don't understand the phrase of binge drinking. Binge drinking for men refers to more than four alcoholic drinks at one setting, and for women, at more than three at one setting. That would be generally over the course of a few hours.

Now, we are not saying here that people should not drink at all. What we're saying is that for people who drink heavily, there are serious health problems, and there is a really important new thing that we understand, which is that brief intervention, that is alcohol screening and brief counseling, can substantially reduce the amount of alcohol consumed on occasion, and unfortunately, alcohol screening and brief intervention is not happening often enough. Now, what does that consist of? Alcohol screening can be done very simply by a-- using a form or a couple of quick question, and brief intervention or brief counseling is a conversation with a health worker -- can be the doctor, can be the nurse, can be a variety of other people in the practice, or in the health care system -- that focuses on what the patient is doing what the patient wants to do, and a plan for what the patient will do in the future. It sounds so simple that it's hard to believe, but it is very effective for many patients. Counseling for five, ten, or no more than 15 minutes can result in a substantial reduction in problem drinking. Drinking too much alcohol has a lot more risks than most people realize, and alcohol screening and counseling can help people set realistic goals for themselves and help them achieve those goals.

Now, what we did at CDC is analyze data from 44 states and the District of Columbia from 2011 and we found that the vast majority of people who see a doctor are not talking about alcohol, even three-quarters of people who are binge drinkers have not talked with their doctor about alcohol use, and even two-thirds of binge drinkers who binge at least ten times a month, have not discussed drinking with a health professional. In fact, only one out of six pregnant women have talked about drinking with their doctor and other health professional, and this was a case across all of the U.S. There was no state or district in which more than one out of four adults had talked with their health professional. We have a couple things coming together. One is that excess drinking is a serious problem in our society. Second, we have this tool, this technique that works really well to address it, but the third is, it's not being applied. Now, the first step in screening a patient is to use a set of questions on a form or asked by a provider, and that's followed by the counseling. Alcohol screening and brief intervention can occur in many different settings, primary care, OB GYN, emergency departments. It's already used as a routine in some trauma settings. Health professionals and health systems can implement alcohol screening and brief intervention by developing support within medical practices, using current guidelines, developing a plan and making it a standard practice, training staff on how to deliver the service, and pilot testing it and refining it to make it happen well. There are at least a couple of examples where whole health systems are doing this. In northern California, Kaiser Permanente has begun this just over the past half year. They've now provided more than 200,000 patients with brief onsite intervention or a referral to help reduce drinking if the patient wants to. In New York City the health department has been screening people in their sexually transmitted disease clinics, and they've been able to screen and counsel tens of thousands of patients through that. Doctors aren't the only ones who can deliver screening and brief counseling. Nurses, social workers, psychologists, health educators and others, can also be trained and effectively deliver this service. It should be a part of routine patient care. In the same way we screen patients for high blood pressure, high cholesterol, we should be screening for excess alcohol use and then respond appropriately.

Now, interestingly, health insurance plans can include this as part of a standard service, and integrate it with electronic health records to increase implementation, and there are many electronic tools that can be used to help deliver screening and counseling and make it easier for busy medical settings to address this. The Community Preventive Services Task Force recommends the use of electronic methods with computer and smartphones and mobile devices to deliver alcohol screening and brief intervention, because there's strong evidence it works. The federal government is now studying how best to achieve alcohol screening and brief counseling, and teach providers how to build and how to ensure that insurance covers this. The Affordable Care Act requires that new health insurance plans cover this service without any co-payment by the patients. We want all health professionals to screen their adult patients for alcohol use, because this works. Health professionals can support their patients by advising them of the U.S. dietary guidelines which recommend that people drink in moderation, if they choose to drink, don't drink at all if they're under age 21, if they might be pregnant, if they have any health problem that can be made worse by drinking, or if they're going to be driving or operating major machinery.

The bottom line here is that drinking too much is a big problem among U.S. adults. It shouldn't get a free pass when it comes to screenings by health professionals, but should be a part of all the screenings that are provided. Health professionals can use alcohol screening and brief intervention to help patients who drink too much drink less. And it takes only a few minutes to deliver. Through the Affordable Care Act, more Americans will have access to health coverage and preventive services, such as alcohol screening and brief intervention, without co-payment. So, thank you for joining us today and helping to get the word out about the importance of addressing this important health issue. I'll stop here and we can take some questions.

TOM SKINNER: Christi, I think we're ready for question, please.

OPERATOR: If you would like to ask a question, please press star 1. One moment, please. Our first question is from Deborah Brauser with Medscape Medical News.

DEBORAH BRAUSER: Hi, doctor. I have two quick questions for you. First of all, you've kind of touched on this, but if you were to boil it all down, would you say your number one recommendation for clinicians is really to screen absolutely all adult patients, not just the ones that you see as at-risk And the second question is, you mentioned, in the actual report, that the finding about the one in six being asked about current alcohol use hasn't really changed much in 15 years. Why do you think that is?

TOM FRIEDEN: Yes. We really do want this to be routine, we know that if doctors try to use their pre conceived notions of who may be at risk, they get it wrong. We all do. So, unless you ask, you can't get the answer. And what we find is that, particularly, issues of alcohol use and addiction are under recognized in the health care system. It may be that physicians are concerned that they won't have the time to deal with the positive answer. It may be that they're concerned about stigma. It may be that they think, incorrectly, that the patient may not be willing to enter into a discussion of the issues. A decade ago, McGlynn published really a landmark article in the New England Journal of Medicine about the quality of medical care in the U.S. One thing that always stood out for me about that article is the area in which the health care system did the worst of all of the areas was in screening and addressing addiction problems, alcohol and other substance abuse. It was down in the single digits for some of the questions that were assessed there. That's why it's really important that it become a routine and that every member of the health care team can play an important role. Doctors are busy, they have lots of things to do, but we can build in screening into routine registration and background questions that are asked about your general health status. It's quite important, not only in and of itself, but as it relates to other health problems like high blood pressure or adherence to medications. And then for those who screen positive there needs to be a routine way of delivering that brief intervention. That might be the doctor, it might be someone else on the team, it might be through an electronic technique of following up with the patient. We need to really move the needle on getting to scale of having conversations with patients, because those conversations can be very effective.

DEBORAH BRAUSER: Thank you.

TOM SKINNER: Next question, Christi.

OPERATOR: Our next question is from David Beasley with Reuters News Service.

DAVID BEASLEY: Yes, Dr. Frieden, is there a good way to describe drinking too much as opposed to binge drinking? I have seen the standards for binge drinking, but what would the standards be for drinking too much?

TOM FRIEDEN: Well, first off, of all of the people who drink too heavily, the vast majority, probably three quarters, binge drink. If you focus on the binge drinking, you'll identify the vast majority of people who drink too much, and we know that binge drinking is quite problematic, because of the possibility of injury as well as other health problems. In terms of excess drinking, the guidelines that are disseminated by NIAAA are basically no more than on average two drinks a day. So that comes out to, for men, no more than 15 drinks-- excess would be 15 or more drinks on average per week. For women, more than one per day or eight or more drinks per week for women on average. And one drink there is five ounces of wine, 12 ounces of beer or one and a half ounces of distilled spirits or liquor.

DAVID BEASLEY: Thank you.

OPERATOR: Our next question is from Dan Childs with ABC.

DAN CHILDS: I just had a quick one. Why do you feel like it's important to have this message out there now? Is this a growing problem, or is this perceived to be a growing problem amongst adults?

TOM FRIEDEN: What we've seen at levels increased in the '90s, and have basically stayed stable since then. But there's still rates of problem drinking are still quite high. 88,000 people a year dying from alcohol and more than 200 dollars billion a year in societal costs. This is a heavy price to pay. In fact, if you look at the underlying causes of death in this country, alcohol is number four. Smoking is number one. Poor nutrition and lack of physical activity, numbers two and three, and alcohol number four. So, it is really one of the major drivers of preventable health problems in this country and around the world.

DAN CHILDS: Thank you.

OPERATOR: Our next question is from Kim Painter with USA Today.

KIM PAINTER: Hi. So, today's report is about adults. But what about adolescents who, of course, do some problem drinking, and are a population you're concerned about too?

TOM FRIEDEN: Yeah. We don't have as good an evidence base on what works in terms of counseling and brief intervention to reduce drinking in adolescents. We know that the earlier someone starts to drink the more likely it is they will have problems with alcohol over the course of their life and there are a number of interventions that have been proven to reduce youth drinking and those are reviewed by the community guide and on our website. There's a range of interventions. But in terms of specific screening and counseling, that's something we can get back to you with in more detail.

OPERATOR: Our next question is from Eben Brown, with Fox News radio.

EBEN BROWN: Evan Brown, actually. First question what counts as a brief intervention and why is it different than other types of intervention?

TOM FRIEDEN: A brief intervention is a structured counseling experience. It's a form of motivational interviewing. And it consists of a few key characteristics: working with the patient to define what their level of drinking is, looking at what are some of the problems that that brings with them, working with them on what are realistic plans that they want to achieve to reduce their amount of drinking. It might mean going from having, you know, six drinks on a Friday night to having three or four. And thinking about, in detail, how are they going to do that. That might mean spacing them out. That might mean drinking things beside alcohol when they're thirsty also, and having a way of following it up. This is a technique that can be taught to a health professional and a variety of other individuals in the community that can be motivational to reduce heavy drinking and can be effective. It involves listening to the patient and giving detailed feedback. What is striking is, many patients who have problem drinking patterns and unhealthy drinking patterns don't recognize that it's an unhealthy drinking pattern. And if the doctor isn't having that discussion, they can't be informed of that. And although certainly not every person is going to want to address that, many will. And of those who want to, many will be successful. But unless you ask, you can't have the conversation.

EBEN BROWN: Okay. Follow-up question real quick. Obviously, the drinking problem among Americans is not necessarily news. Why are you telling us about this today? Is it the fact that this service is now more widely available under new health care laws or is this something that was crossing your mind?

TOM FRIEDEN: Well, we have new data. So, for the first time in a while, we looked at how often our doctors and other health professionals, talking with their patients about drinking, and we have this data from 44 states and the District of Columbia. We didn't have it before. So, this is a new data release, and what it shows is it's not happening. What it shows is that even among those who binge drink, three quarters not having a conversation with a health professional. Even among those who binge drink ten times a month or more. Two thirds are not having that discussion with a health professional. We have new data. The new data shows these conversations are not happening. It is also the case that we have new knowledge these interventions are very effective and simple to apply and new opportunities for people to undergo brief intervention because of more coverage, and because there's a requirement to cover brief intervention without co-pay. And the reason for that requirement is that it's a recommended service of the US Preventive Service Task Force, and the reasoning behind that is very straightforward. If there's something that works as prevention, we shouldn't make people pay for it.

OPERATOR: Our next question from Nancy Shute with NPR.

NANCY SHUTE: Yes. You're saying that doctors aren't doing their job and it's obviously going to take a while to turn this around because there hasn't been much change in years. What are patients supposed to do about this?

TOM FRIEDEN: Well, patients-- there are a lot of electronic tools that patients can use online. They can go on to the web and assess themselves. And if they are seeing a doctor, they can bring it up. If they're asked about it they can be open about the discussion. The goal here is not tell people never take another drink unless there are people who cannot drink safely, the goal here is to have a conversation about what is the pattern of drinking for each individual that is least likely to lead to harm.

TOM SKINNER: Next question.

OPERATOR: Our next question is from Elizabeth Kuhr with Time Magazine.

ELIZABETH KUHR: Hi, there. Thank you. I was wondering what your suggestion is for those not see doctors. You mentioned education. But if you had any other ideas?

TOM FRIEDEN: Well, there are a lot of tools available online. You can assess your own drinking. You can get assistance to cut it down if it's too high. So, we encourage people to get into care and to see a doctor regularly to see what resources are available. But there are also lots of electronic tools out there. There are also lots of community groups that are available to talk with people and be involved in to reduce problem drinking.

ELIZABETH KUHR: Okay. Thanks.

OPERATOR: Our next question is from John Reichard with Congressional Quarterly.

JOHN REICHARD: Hi. Thanks. I don't know if you covered this or not exactly. But what I wonder about is the extent to which insurance coverage still remains an issue, even though the Affordable Care Act is requiring coverage. And if you could touch on what Medicaid and Medicare benefits are in this area?

TOM FRIEDEN: Thanks, John. I think, you know, frankly, there's a gap between saying it has to be provided without copay, and saying it has to be provided. We know doctors are busy, medical practices are busy. The places that have been able to scale this up effectively have used a team approach. Have had trained counselors, following up on patients who screen positive. And so while it's a covered service under Medicare and Medicaid, and while new plans need to provide it without copay, one of the reasons we're releasing this report is we're not getting to scale in delivery of this intervention. And groups like Kaiser Permanente of northern California have shown the way to do that. They've provide hundreds of thousands of brief interventions in just a few months after making this part of their system. And I think that's what we find often with health care. It's not enough, just as it's not enough to say to a patient you should do x or y. It’s not enough to say to doctors you should do z or y. We need to look at the whole system and to reduce problem drinking, brief intervention is one tool. There are a series of other tools different communities can consider. Those are outlined in our community guide. And for medical practices there are a series of interventions needed to set up a system. There's not a question, oh, did I remember to do that. But it's a routine checklist of what gets screened for, and for people who screen positive, how they get followed up.

JOHN REICHARD: Okay. Thank you.

OPERATOR: Once again, to ask your question, please press star 1. Brian Krans with Healthline News.

BRIAN KRANS: Hi, Dr. Frieden. I know we're talking about binge drinking and problem drinking. For everyone listening to the news coverage or this, what are good signs people's habits are starting to border on alcoholism?

TOM FRIEDEN: Again. As I said at the outset, for every one person who has alcoholism, there are at least six who are problem drinkers. So the vast majority of the harms from alcohol are caused by people who are not alcoholic. But, for the people who are wondering whether they may have alcoholism, some of the clues to that is if someone continues to drink despite having serious problems with their life. So they're unable to stop, despite having physical, psychological, social, or other problems, not being able to cut down or stop. Not being able to stick to limits of drinking, needing to drink more and more to get the same effect, having withdrawal if they stop drinking. All of these are clues that it may have progressed from heavy drinking to alcoholism.

BRIAN KRANS: Thank you.

OPERATOR: There are no further questions.

TOM FRIEDEN: Okay. Well, I want to thank everyone for joining us. I know when we discuss alcohol, people sometimes think oh my goodness, why are you raising this issue? We are not saying that no one should drink. Most people who drink do so without adverse health problems. But, for many people who drink, they drink too much, too much at a time, or too much overall, and that causes a very wide range of health problems and the new data that we're releasing today shows that the health system is not doing an effective job finding out about those problems and helping patients who want to reduce their alcohol use to reduce it. We do have this very effective technique of brief counseling that substantially reduces problem drinking, but isn't yet being applied, so we're looking forward to working with an increasing number of health systems, health providers, community groups and others to see this new intervention, this new technique more rapidly applied and we appreciate your interest and your coverage.

TOM SKINNER: Thank you. Christi, this concludes our call and reporters who may have follow-up questions or need additional information can call the CDC press office at 404-639-3286. So, thank you once again for joining us.

OPERATOR: Thank you for participating in today's conference, the conference has concluded and you may disconnect at this time.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES