I’m a pediatrician, and when I see adolescents in my clinic, I ask them if they are drinking alcohol (among other risky activities). Then I counsel them if they answer in the affirmative. I want young people to be safe.
But doctors lack the evidence base — we don’t have enough studies — to know how much of a difference this makes.
Here’s why we may want an answer. Excessive drinking is responsible for 88,000 deaths per year in the United States, about one in 10 deaths among working-age adults. The cost in 2010 was almost $250 billion.
And drinking is a serious problem among adolescents. More than 9 percent of those 12 to 17 years drink alcohol, and almost 5 percent engaged in binge drinking in the last month.
We know how to screen people for alcohol misuse. It’s not hard. The Alcohol Use Disorders Identification Test-Consumption asks three simple questions: how often people drink, how much, and how often they drink heavily.
The Single Alcohol Screening Question asks simply, “How many times in the past year have you had 5 (men)/4 (women) or more drinks in a day?”
The latter is positive (when the answer is more than once) in about 80 percent of people who have unhealthy use of alcohol (as defined by the National Institute on Alcohol Abuse and Alcoholism) and negative in about 80 percent of people who do not. That’s pretty good for a quick one-question screen.
There are also specific screening tools that have been validated for pregnant women, adolescents and older people.
Asking a question in a visit costs very little, other than time. It also has few harms. So why not recommend it for everyone?
Screening is useful when a condition is prevalent, when we can screen in a cost-effective manner, when early diagnosis makes a difference, and when we know that acting on that screen will make a difference.
Dr. Susan Curry, the immediate past chairwoman of the U.S. Preventive Services Task Force, told me: “There have simply not been enough studies that assess the effects of screening and behavioral counseling in adolescents to address this issue. In addition, many of the existing studies have been conducted in school settings, and it is unclear if the results would translate to primary care.”
The effects of behavioral counseling on adults are proven enough to show a moderate benefit. The same holds true for pregnant women, although the evidence is a bit less strong. But when it comes to adolescents, the evidence is almost nonexistent.
In a large systematic review, there were two studies (out of 68 total) that addressed how counseling interventions might affect adolescent alcohol use. One was a randomized controlled trial of 119 urban adolescents screened in a medical clinic, published in 2015, that used peer networks and motivational interviewing. Over all, it failed to achieve statistical significance with respect to reducing alcohol use.
The other was a 2017 randomized controlled trial in Switzerland schools (not clinics) of a web-and-text-based peer-network messaging system to reduce single-occasion binge drinking. It decreased the chance of that happening by 5.9 percent in the intervention group. But it had no effect on how much youths drank over all or the estimated peak blood alcohol concentration during binge drinking.
That’s all we’ve got. And before 2015, there was nothing.
“We are calling for additional research in all areas related to screening adolescents for alcohol use and providing counseling interventions to those who need them,” Dr. Curry said. “It is also important to explore whether such interventions could reduce other risky behaviors. In the meantime, we encourage primary care clinicians to use their clinical judgment when deciding whether to screen their adolescent patients for alcohol use.”
There’s disagreement on the definition of unhealthy alcohol use for adults.
For men, risky drinking is more than four drinks on any day or more than 14 drinks in any week, according to the national institute. And for women, it’s more than three drinks on any day or more than seven drinks in any week. (The institute defines a drink as 12 ounces of beer, 5 ounces of wine or 1.5 ounces of spirits.)
The American Society of Addiction Medicine, on the other hand, defines “at-risk use” as “use that increases the risk for health consequences.”
Young people tend to consume more alcoholic beverages when they’re drinking than adults do. Most of their drinking is binge drinking. Excessive drinking among adolescents — what we’re talking about screening for here — accounts for more than 4,300 deaths each year.
The economic costs of excessive drinking in just this population were $24 billion in 2010. Of those who drive, about 8 percent report having driven after drinking alcohol; 20 percent report having been in a car with someone who had been drinking. About 20 percent of teenage drivers who have died in crashes had been drinking.
Physicians who assure confidentiality and earn the trust of their patients can screen for alcohol use in adolescents pretty well. It’s not that we can’t uncover the problem. I’m often humbled by what my young patients will tell me in private. The issue is that we don’t have the knowledge for what to do with a “yes.” We don’t know that what we’re doing actually helps.
Although it endorsed screening of adults and pregnant women in a recent statement, the United States Preventive Services Task Force did not recommend universal screening for alcohol use among adolescents in primary care settings. That speaks more to a failure of our knowledge base — we need more studies — than to the failure of the recommending body to recognize the importance of the problem.