Alcohol use disorder (AUD) is a global problem. It affects 20 million Americans and is associated with significant human and financial costs [1,2]. It is the third leading cause of preventable death [3]. Approximately 3 of 10 American adults drink in a risky way [4] and with 80% of the adolescent population having used alcohol this year this is likely to continue to rise [5]. A greater prevalence is noted in clinical populations especially those that are undergoing psychiatric treatment [2]. In fact, those with mental illness consume 38% of all alcohol sold [6]. On-going use complicates the course of medical and psychiatric conditions and carries significant risk for social exclusion. Sufferers, once identified, could be prompted into treatment involving both psychosocial approaches as well as diverse pharmacotherapy with proven efficacy on relapse rate [7,8]. A most recent national survey indicates, however, that those dealing with alcoholism rarely receive medications as only 3% of sufferers receive FDA-approved treatment [1].

Screening for disease is the mainstay in today’s preventive health care practices allowing for early identification of those at risk of having a specific condition. In the case of alcohol misuse, screening assesses whether an individual may have an AUD or is at risk of experiencing problems from alcohol use. Screening can be conducted in various settings, by different professionals, either through interview or selfadministered questionnaires. Early screening tools such as the Michigan Alcohol Screening Test (MAST) and the Cut Down- Annoyed, Guilty Eye opener (CAGE) questionnaire were developed to detect alcohol dependence. Over time, other instruments were introduced to assist with identification of risky and hazardous use in order to facilitate brief interventions early in those at risk and to facilitate treatment referral. In 1981 WHO developed internationally validated screening tools [9] for misuse such as the Alcohol Use Disorders Identification Test (AUDIT) [10]. Many agencies have made recommendations for integration of such tools in health care systems [11]. As screening’s effectiveness has been demonstrated the demand for instruments has increased. Currently there are several available that can be individualized to identify various subgroups of the population at risk.

Objective

Here we report findings from a survey of mental health providers with the main hypothesis being that use of screening tools translates into more medication prescriptions to address AUD. We also review the available screening tools with emphasis on when clinicians should utilize them.

Screening tools

There are many screening instruments available that can detect alcohol misuse with acceptable sensitivity and specificity. For the vast majority the AUDIT, or a two-part question inquiring about frequency and amount of consumption, suffices [12]. The US Preventive Services Task Force (USPSTF) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) have recently recommended that all primary care providers should screen adults over 18 yrs of age for alcohol misuse using either the AUDIT, abbreviated AUDIT-C, or single question such as “How many times in the past year have you had 5 (for men) or 4 (for women and all over 65 yrs of age) or more drinks in a day?”. It has also been recommended that those at high risk be provided brief counseling interventions or referral to treatment if a more serious problem is found [13].

For greater accuracy, each tool available is designed with a particular target population in mind (age, race, language, inner city vs. rural, etc), time available with the patient and whether it is self or clinician administered. Designers of such have also taken into consideration that questionnaires that are too long are unrealistic for routine clinical use and those that are too short may not provide enough information. Also, self-report, paper based instruments, tend to provide more open disclosure than clinician administered instruments. Each tool available places a different importance on alcohol dependence versus hazardous and risky use.

The AUDIT was developed by Saunders et al under the auspices of the World health Organization [14]. The main focus was excessive drinking and 10 questions were chosen from 150 alternatives. They made recommendations on implementing the tool in various health care settings [14]. One of the advantages over other tools is that it identifies excessive drinkers who are not yet dependent and who have not yet come under attention for alcohol-related medical issues. It accomplishes this with 92% sensitivity and 94% specificity [10]. It employs a current time frame focusing on last 12 months (questions 1-8) as well as lifetime (questions 9, 10). It also assesses alcohol intake (questions 1-3), dependence (questions 4-6) and alcohol related problems (questions 7-10). All items range from 0-4 with a maximum score of 40. A short version, AUDIT-Consumption (AUDIT-C) consists of the first 3 questions which cover frequency and amount of use and frequency of binge drinking. Proposed cutoff points for hazardous drinking are ≥ 8 for AUDIT and ≥ 3 or ≥ 4 for AUDIT-C for identifying alcohol problems [15]. Additional screening tools are summarized in Table 1.

Table 1: Available screening tools.

There are several pharmacological treatment options that can be employed for the treatment of alcohol use disorder with minimal disruption to home and work life. Despite small to medium effect sizes these have shown proven overall efficacy to provide an important improvement in relapse rate [8]. It is advised to start with FDAapproved medications-Disulfiram for the motivated patient desiring sobriety [25,26], Naltrexone for most patients [27-30] and consider long acting injectable [31,32] if affordable, Acamprosate for those with established sobriety and may help with post withdrawal sleep problems as well [33,34]. Off-label considerations include Topiramate which has the highest evidence for efficacy [35] and Gabapentin, either alone or combined with Naltrexone, which is helpful especially to help with sleep, anxiety and withdrawal [36].

Methods

A 19-question survey was designed and distributed via Qualtrics (https://www.qualtrics.com) to prescribers involved in treatment of those with mental health illnesses in North Carolina. Although the four major academic institutions (East Carolina University, University of North Carolina, Duke University and Wake Forest University) were targeted, the survey was also distributed through the state psychiatric association’s newsletter to community and chemical dependence providers. The survey was initially distributed May 15, 2016 and was available for 1 month with 3 weekly reminders sent out to nonresponders. Within our institution, response rate was 85%. The final number of participants who completed the survey was 170. Through the use of an individualized link, participants were anonymously electronically registered. Responses were completely anonymous with no IP addresses or personal identifiers being collected. Data was gathered and further analyzed by Qualtrics and also a statistician. The study conductors have no disclosures and this study was exempt from East Carolina University Institutionalized Review Board (IRB) review (UMCIRB 16-000974) (Figures 1 and 2).

Figure 1: Characterization of survey participants.
Horizontal axis represents number of responders.

Figure 2: General practice survey.
Horizontal axis represents number of responders.

Among providers associated with academic institutions, close to half of patients seen in a primary psychiatric setting have been reported to have comorbid alcohol use disorders. This is troubling since evidence based screening for alcohol use disorders was avoided with almost half of the providers reporting they never use tools such as AUDIT. Kruskal-Wallis ANOVA revealed that type of institution significantly affected the frequency of use of AUDIT, χ2(2, N=141)=16.35, p medications despite a majority of patients being interested in treatment. Shockingly, 20% of providers have never prescribed any and those that do prescribe seem to favour off label medications over FDA approved. When patients are identified and medications are prescribed, providers seem to have had very positive experiences indicating patients tend to maintain sobriety longer, have less legal problems and are better able to engage in their medical and psychiatric care.

Frequency of use of both FDA-approved and off label medications was significantly higher among those who reported using evidencebased screening tools (Mdn=39.2%) than among those who did not (Mdn=23.5%), U=1284.5, p<0.001.

This study sampled a relatively wide variety of providers and settings within the boundaries of North Carolina. The numbers of Veterans Affairs participants were not significant and hence no interpretations can be made regarding their practices. Whether there is generalizability of the practices of nationwide providers cannot be confirmed. The number of responders participating is relatively low; however, the high response rate increases the validity.

Alcohol use disorders are highly prevalent and disabling disorders that often go undiagnosed and subsequently untreated. Their comorbidity impedes treatment and social functioning of individuals with mental illnesses. It is imperative that individuals presenting for treatment of psychopathology be adequately screened for comorbid AUDs. Even in absence of AUDs, risky use may contraindicate use of some potentially useful psychotropics. The AUDIT tool has high enough sensitivity, specificity and generativity to be used in the average patient in a general mental health setting.

Treatment guidelines for AUDs recommend FDA approved medications in conjunction with biopsychosocial interventions. As seen, identification alone does not necessarily result in pharmacological implementation. Proper screening with tools such as the AUDIT although poorly utilized, may better identify suffers and facilitate discussion for treatment implementation. Use of AUDIT leads to better outcomes as prescribers that screen seem to be less hesitant in using pharmacotherapy in their patients.

As part of routine practices, general psychiatrists should implement screening, using a tool such as the AUDIT to identify patients with risky alcohol use.

The authors report no relevant financial conflicts.