When people think of an assessment of an individual “Drinking too Much,” they often think, such an assessment applies to alcoholics or that the standards of what is considered, “too much” are unrealistically low considering social norms. Actually, most people who drink too much are not alcoholics, the 4% of the population that are alcohol-dependent (i.e. alcoholic). However, those who fit the criteria for drinking “too much” make up 30% of the country’s population. More importantly, this 30% of the population are at risk of the 4th Leading Preventable Cause of Death in the United States.
I’m often asked in one form or another, “how much is too much?” According to the U.S. Centers for Disease Control and Prevention, the general guideline for too much drinking includes binge drinking or high per-occasion use (5 or more drinks on an occasion for men and 4 or more for women), high weekly use, and any alcohol use by pregnant women or those under age 21. Again, these are the general guidelines.
Given those guidelines, at least 38 million adults in the United States drink too much alcohol, leading to a wide range of negative consequences, including heart disease, breast cancer, sexually transmitted diseases, fetal alcohol spectrum disorders, motor vehicle crashes, and violence. Drinking too much alcohol accounts for about 88,000 deaths in the United States each year, and in 2006 alone cost the country about $224 billion.
Even though more than 30 years of research has shown that alcohol screening and brief counseling is effective at reducing risky drinking, the CDC reported this month that only 1 in 6 adults — and only 1 in 4 binge drinkers — report an instance where a healthcare professional has ever talked about alcohol use with them unless the practitioner was sought for the purpose of discussing their alcohol use. The CDC is now recommending that alcohol screening and brief counseling interventions (as short as 6-15 minutes), should be provided irrespective of the nature of the appointment with the healthcare professional. Psychotherapists as well as physicians are recommended to incorporate alcohol screening and brief counseling intervention to ALL of their patients. These recommendations involve the patient’s active participation and the screening is recommended to be as effective if provided electronically due to the higher instance of more accurate reporting via electronic screening than looking at your provider and telling them the exact nature of your alcohol consumption habits. Remarkably, the same holds true when it comes to many other health related issues, especially in male patients. Come on, you’ve never flossed more frequently in the days leading up to a dental appointment or hit the gym more frequently prior to an annual physical. It’s human nature not to want to avoid embarrassment, perceived or otherwise.
With the frustrating and confusing nature of healthcare insurance, it often seems that additional services = additional payment. This consensus is widely held by practitioner and patient alike. However, The Affordable Care Act requires new health insurance plans to cover alcohol screening and brief counseling without a copayment. Call me biased, but how can a practitioner not ask about about how a patient lives their life and what they experience physically and emotionally? Diet, sleep, stress, exercise, relationships, personal and professional satisfaction, obstacles, responsibilities, pressures, support mechanisms are starting points. If you’re asked by a healthcare professional if you smoke and you say, ‘yes,’ is it fathomable that you’ll then only hear, “ok?” If you’re in this scenario and you’re not asked followup questions, run for zee hills! If you’re asked “Do you it’s bad for you?” then follow the same instructions, but this time, really run zee hills- and fast!
I’m aware of those that ask some variation of how often do you drink, rather than if you drink. That’s not always an indication to run (although there’s a good chance it merits a brisk walk). Socially, drinking alcohol even if on occasion, is the norm. Some practitioners might ask how much you drink rather than do you drink as a means of getting the most accurate data regarding their patient’s alcohol use. You’ve in effect been told by the nature of the question, that drinking is expected. Obviously, those who drink responsibly, are not causing harm to themselves like those who smoke. I’ve yet to see an ad that says, “Enjoy Marlboro Country….Responsibly.” Duh.
A practitioner should foster a comfortable environment where you don’t feel like you’re testifying. Although, some providers do have an office, examining room, etc., that has the feel of an interrogation room (sans the one way mirror), but hopefully that’s not your experience. Along with making my clients comfortable and at ease, I utilize the most appropriate and validated screening tools specific to the individual. That holds true whether I’m asking them their address or sensitive and personal questions.
The latest screening tools for alcohol use (and there are many) that I use are such tools that are often developed by collaborations of teams comprised of experts in a particular population’s (or segment of our society’s) alcohol use. For example, the National Institute of Alcohol Abuse and Alcoholism (NIAAA), one of the 28 Institutes at the National Institues of Health (NIH), has a devoted team of experts on underage drinking who along with the American Academy of Pediatrics, collaborated in creating an empirically based screening tool and comprehensive guide (amongst many supporting research studies and peer-reviewed materials) for clinicians to utilize with the youth they serve. This group of leading researchers and clinical practitioners whose expertise in all facets of underage drinking created these screening tools and guidelines to allow clinicians such as myself to adhere to the basic responsibility of providing for the specific individual. Along with many other resources from such institutions as the American Psychiatric Association and the American Psychological Association, as well as countless other organizations representing specialties, such as the entities for which every specialty has many, have amassed an arsenal of their own such research and subsequent treatment recommendations. Practitioners have the responsibility to continue their education (and often their licensure requires them to formally do so), to not only have the most current knowledge of research and practice as it evolves, but the ability to provide the most appropriate evidence based treatment to those in need, covering the diverse population in a fast moving world. Many practitioners are struggling with the new laws requiring them to adopt technology. I embrace it, however the manner in which the laws are being communicated are as clear as mud. Which, is another reason why continuing education is so important and in mental health, there are resources and continuing education courses available which make sense of the laws. In all fairness, had I not been a tech geek, I may have found these educational resources confusing, especially if I had only been using paper and pen for years.
Alas, I regress. Screening for alcohol abuse criteria cannot be considered without taking in as many factors as possible. Different criteria exist based on a miriad of factors. You can’t measure the drinking habits of college students and senior citizens with the same measuring stick. Within those groups, one must consider additional factors beyond age and gender as well. Your practitioner must go beyond the surface of basic demographics, as we are as individual as our fingerprints.
The good news is the ongoing data collection, (I’m talking about research studies with informed consent, not Big Brother spying on alcohol use) is thoroughly analyzed and used in developing such specific tools such as those mentioned above and screenings which can now be done electronically have been shown to be powerful predictors of current and future negative consequences of alcohol use. There are secure methods in which to screen electronically, and certainly, it is not a requirement, but given that the majority of today’s youth’s communication method of preference is electronic, this is a segment of the population where alcohol abuse screening is crucial as 1 in 3 children start drinking by the end of 8th grade. Half of which report having been drunk at least once by that same age.
Counseling or a brief conversation with those who drink too much serves to inform the individual about health problems that could occur as a result of their drinking, and lead to the desire to reduce or stop drinking (if they do not already want to should they have a problem with alcohol). Those who agree to reduce or stop their drinking are supported through therapy and followup to assess their success.
The above mentioned CDC recommendations of brief counseling interventions (as short as 6-15 minutes) as part of alcohol screening has been shown to help reduce average alcohol use by over 3 drinks per week, reduce episodes of binge-level alcohol use by 12%, as well as improve adherence to recommended drinking limits.
These effects can last for years and can also lead to reduced need for additional need for healthcare related to alcohol abuse, including fewer hospital days and lower costs. Only a very small percentage of those who are screened will have indications of alcoholism or a severe alcohol use disorder, for which specialized treatment is available.
Ultimately, that is the point. Proper help is available.
If you are concerned that you or someone you care about has a problem with alcohol, it may not feel like it, but help is truly available. For more information including setting up an in person or electronic alcohol screening, please feel free to contact me. You won’t want to head for zee hills. It’s possible you might want to head for zee bar. If that’s the case, we’ve tackled the screening and now it’s time to move onto the path of recovery. The idea is scarier than the process. That I can promise.
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