Alcohol use-related problems in general hospitals and primary care settings: Screening, intervention, and referral to treatment

Abstract

Alcohol use has contributed to large disease burdens, and alcohol-related problems are prevalent among patients in general hospitals and primary care settings. This review aims to deepen the understanding of screening, intervention, and treatment referral for alcohol-related problems in these settings. We searched the literature published in English from PubMed, ScienceDirect, and the World Health Organization website. We found that while a series of screening tools can be used, screening rates were low. The awareness of screening should be strengthened. Brief interventions and pharmacotherapy are the two main methods used in general hospitals and primary care settings, with complementary and alternative medicine considered under the framework of integrative medicine. Individuals with severe alcohol-related problems or alcohol use disorders should be referred to specialty treatment for alcohol abuse, but referral is sometimes ignored. A gap exists between general hospitals/primary care facilities and specialized alcohol-related treatment providers. In conclusion, screening, intervention, and referral to treatment comprise a continuum for patients with alcohol-related problems. Opportunities to prevent and manage these problems in general hospitals and primary care settings are abundant, and taking action will promote the addressing of this public health issue.

Key Words: Alcohol use disorder; Treatment; General hospital; Primary care; Screening, brief intervention, and referral to treatment

Core Tip: This mini review provides a full perspective on how alcohol-related problems can be addressed in general hospitals and primary care settings. Because general hospitals and primary care settings have good opportunities to implement these measures. In summary, screening, intervention, and referral to treatment constitute a continuum. These steps manage alcohol-related problems on different severities.

INTRODUCTION

Alcohol, also known as ethanol, has a long history with humans[1]. It is assumed to have played roles in food seeking and appetite stimulation over the course of evolution[1]. Alcohol can act pharmacologically on the central nervous system, affecting multiple neurotransmitter systems and the neuroendocrine system[2]. As alcohol is a psychoactive substance, its overconsumption can lead to abuse and even addiction in humans[1]. Per-capita alcohol consumption increased globally in the first two decades of the 21st century[3,4]. Notably, this increase was significant in lower- to middle-income countries such as India and Vietnam[4]. Alcohol consumption is forecast to increase further by 2030[3,4].

Alcohol use has contributed to large disease burdens and is the leading risk factor for those aged 25-49 years, according to the 2019 Global Burden of Disease Study[5]. Excessive alcohol use can cause alcohol-related problems ranging from risky drinking to alcohol abuse or dependence and alcohol use disorders (AUDs)[6]. AUDs are the most prevalent of all substance use disorders[7], with consequences including health problems, social function impairment, and occupational issues.

Alcohol-related problems are more prevalent among patients in general hospitals and primary care settings than in the general population[8]. Over a 1-year period, up to 16% of inpatients in a 999-bed general hospital had unhealthy substance (including alcohol) use patterns[9]. Reported percentages of primary care patients with AUD range from 3.1% to 7.3%[10,11].

To address the huge public health challenges posed by alcohol use-related problems, general hospitals and primary care physicians provide windows for their management. The implementation of the screening, brief intervention, and referral to treatment (SBIRT) model plays key roles in the reduction of patients’ heavy drinking and promotion of treatment for severe alcohol-related problems[12]. In contrast to a previous focus on other somatic diseases, healthcare practitioners now have opportunities to screen patients for alcohol use-related problems and provide first-step interventions. Patients with severe alcohol-related problems can be referred to specialized treatment services. This stepwise approach increases the chance that patients will become involved in their treatment, reduce their alcohol consumption, and achieve improved recovery. In this mini review, we provide an overview of the alcohol use-related screening, intervention, and referral processes used in general hospitals and primary care settings, and summarize existing barriers and challenges.

SCREENING FOR ALCOHOL USE-RELATED PROBLEMS

Healthcare practitioners (e.g., physicians and nurses) in general hospitals and primary care settings should be aware of patient screening for alcohol use-related problems, such as the screening opportunities and available instruments. Following the identification of patients with problematic alcohol use, they have opportunities to implement interventions. However, screening implementation rates are inadequate[13-15]. During the period of 2014-2016, only 2.6% of primary care visits in the United States involved alcohol use-related screening with a validated questionnaire[13]. More recent studies have shown that screening rates remain low[14,15]. A study published in 2023 showed that clinicians in primary care practices in Virginia, the United States, screened about 10.8% of patients[15]. A 2024 survey revealed that 22% of 282 physicians and 295 nurses in Hong Kong, China had applied alcohol use-related screening in the past year[14].

Healthcare practitioners have positive attitudes toward such screening[16], but several factors influence its implementation. Barriers include a lack of training[17], the stigma surrounding AUD[16,18], implementation-related costs[19], social and cultural attitudes[20], the impracticality of screening tools[20], and resulting workflow increases and disruption[18]. Facilitators of screening include better knowledge[14], greater self-efficacy[14], positive beliefs[19], a commitment to leadership[21], resource availability[19], and clear planning for screening[14].

Available screening tools, based on chronological sequence, include the CAGE questionnaire[22]; the AUDs Identification Test (AUDIT)[23]; the consumption-focused derivative of AUDIT (AUDIT-C)[24]; and the Screening Test for At-risk Drinking (STAD)[25]; the Alcohol, Smoking and Substance Involvement Screening Test[26]; the Single Alcohol Screening Question (SASQ)[27]; the Alcohol Symptom Checklist[28]. Among them, AUDIT and Alcohol, Smoking and Substance Involvement Screening Test are developed by the World Health Organization (WHO) and have been widely used around the world in general hospitals and primary care settings[23,26], which is universally applicable. AUDIT-C (3 items) and STAD (2 items) are derived from AUDIT for more convenient and time saving screens. SASQ contains only one question which is suitable for brief and primary screen and then further for conjoint screens with other tools[27]. The CAGE questionnaire, AUDIT-C, STAD and SASQ are useful in clinical situations with high-volume patients such as emergency departments (EDs)[25]. The Alcohol Symptom Checklist, with indications for severity level of AUD, would be helpful for assessing the severity and managing AUD[28]. The characteristics of the screening tools are summarized in Table 1.

Table 1 Screening tools for alcohol use-related problems.

Tool	Publication year	No. of items	Score range	Cut-off	Recommendations
CAGE	1984	4	0-4	≥ 2, alcohol-related problem	/
AUDIT	1993	10	0-40	≥ 8, hazardous and harmful alcohol use, possible alcohol dependence	Zone I (0-7): Alcohol-related education; Zone II (8-15): Simple advice; Zone III (16-19): Simple advice, brief counseling continued monitoring; Zone IV (20-40): Referral to specialist for diagnostic evaluation and treatment
AUDIT-C	1998	3 (AUDIT Q1, Q2, Q3)	0-12	≥ 3 (women) or ≥ 4 (men), unhealthy alcohol use	/
SASQ	2001	1	/	Response of any time in the past 3 months to “When was the last time you had more than x drinks in one day?” (x = 4 for women, 5 for men)	Positive response: Further assessment
ASSIST	2002	8	0-39 for one substance	For alcohol: ≤ 10, low risk; 11-26, moderate risk; ≥ 27, high risk. For other substances: ≤ 3, lower risk; 4-26, moderate risk; ≥ 27, high risk	Low risk: Feedback, encouragement to remain low risk; Moderate risk: Brief (3-15-minutes) intervention; High risk: Brief intervention, encouragement of detailed clinical assessment and appropriate specialist treatment
Alcohol Symptom Checklist	2015	11	0-11	≥ 2, AUD diagnosis supported AUD severity per DSM-5: 2-3, mild; 4-5, moderate; 6-11, severe	/
STAD	2018	2 (AUDIT Q3 and Q7)	0–8	≥ 2 (women) or ≥ 3 (men), at-risk drinking	/

AUDIT: Alcohol Use Disorders Identification Test; AUDIT-C: Consumption-related AUDIT derivative; ASSIST: Alcohol, Smoking and Substance Involvement Screening Test; AUD: Alcohol use disorder; DSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; SASQ: Single Alcohol Screening Question; STAD: Screening Test for At-risk Drinking.

Screening strategies entail various categories (alcohol use alone, alcohol and other substance use, or alcohol use and other mental illness), models (in the clinic or online), administrators (respondents or clinical staff members), and frequencies (at any visit or at fixed timepoints, such as annually)[29-31]. Electronic health records (EHRs) can be used to promote screening and facilitate related research. The integration of screening tools into EHRs was proven to be feasible and convenient in a clinical setting[32]. Researchers in the United Kingdom developed an AUD codelist based on an EHR database as a reference for practitioners and researchers[33]. In contrast to face-to-face screening, the analysis of EHR data is used to identify populations of patients at high risk of having or developing alcohol-related problems[34]. In the era of big data, machine learning is an optimal solution for EHR analysis, as it allows healthcare practitioners to efficiently identify patients with unhealthy drinking patterns at a large scale[35,36].

Multiple strategies can be applied to raise the awareness of screening at different levels. At the healthcare practitioner level, training and education should be provided in general hospitals and primary care settings and stakeholder relationships should be developed[37]. At the patient level, patients can be engaged in workshops related to alcohol use screening, and volunteer activities can be undertaken in collaboration with Alcoholics Anonymous[37]. At the societal level, public awareness campaigns and policies supporting alcohol use screening can be implemented by national institutes or governments. For instance, National Alcohol Screening Day has been recognized since 1999 in the United States[38].

INTERVENTIONS FOR ALCOHOL USE- RELATED PROBLEMS

Two main intervention types are used for alcohol use-related problems in general hospitals and primary care settings: Brief interventions and pharmacotherapy. Brief interventions, used most widely, can be traced back to the 1980s, when WHO proposed a complementary concept to broaden the management of alcohol-related problems[39]. The original design of the WHO’s brief intervention comprised simple advice, where healthcare practitioners provide 5 minutes of advice on sensible drinking or abstinence, and subsequent brief counseling, where individuals receive 15 minutes of counseling on personal problem solving related to hazardous or harmful drinking[40]. With progress in practice, current brief interventions for alcohol-related problems fall on a continuum ranging from those requiring less than 5 minutes (even 1 minute) in one session to those requiring more than 20 minutes in several sessions[41,42]. The core objectives of these interventions are to provide motivation and promote the development of behavioral change strategies[41,42]. They can be implemented in person or via telephone, text message, computers, mobile phone applications, and website[43-46].

A wealth of practice evidence regarding the use of brief interventions for alcohol-related problems is available. For example, a systematic review showed that studies have produced moderate-quality evidence that brief interventions reduce alcohol consumption in spite of males and females, and low-quality evidence that extended interventions have little additional effect on alcohol consumption[47]. Brief interventions have been confirmed to be broadly applicable, with no difference in results obtained in European and non-European populations and consistent effectiveness demonstrated in low- and middle-income countries[48,49]. In addition, they have been shown to benefit other health outcomes: A brief intervention implemented by primary care physicians to reduce unhealthy drinking improved the blood pressure control of patients with hypertension[50], and another alcohol-related brief intervention reduced veterans’ odds of receiving new opioid prescriptions or opioid use disorder diagnoses[51].

Pharmacotherapy, or medication-assisted treatment for AUD (MAUD), is another important intervention approach used in general hospitals and primary care settings, especially for patients with alcohol dependence. Three effective anti-craving medications [disulfiram, naltrexone (oral and long-acting injectable formulations), and acamprosate] have been approved in the United States for the treatment of AUD[2]. In addition to the three medications listed above, nalmefene has also been approved by the European Medicines Agency[52]. In practice, however, MAUD was underutilized. Medications were prescribed to less than 9% of eligible patients in the United States[2,53]. Exposure to disulfiram or naltrexone monotherapy or to disulfiram combined with naltrexone or acamprosate has been associated with a lower risk of alcohol-related hospitalization among individuals with AUD[54]. As they see large numbers of patients with alcohol-related problems, clinicians in ED and primary care facilities can integrate pharmacotherapy into their daily practice[55,56]. Several studies conducted in EDs have confirmed that the oral and extended-release injection formulations of naltrexone reduce alcohol consumption[57].

Many patients seek help for alcohol-related problems from complementary and alternative medicine (CAM) practices, such as traditional Chinese medicine and acupuncture[58]. CAM has been used in the field of addiction medicine since the 1970s[58]. Although CAM and integrative medicine have yielded equivocal or mixed results for alcohol-related problems[58,59], many patients have health-related interest in and beliefs regarding these treatment methods[58]. In a study conducted in Switzerland, more than 60% of patients had used CAM not only for their alcohol and/or tobacco use, but also for comorbidities[58]. Further investigation of the effectiveness of CAM use for alcohol-related problems is needed. More measures can be implemented to promote the integration of CAM and allopathic medicine into the treatment of alcohol-related problems.

Under the framework of integrative medicine, which emphasizes the whole person, the use of all appropriate therapies, and the patient–practitioner relationship[60], various interventions can be integrated into the treatment of alcohol-related problems in general hospitals and primary care settings. For example, brief interventions can be combined with MAUD[56]. One study explored that a flexible, facilitator-supported, tailored implementation model could meet clinical needs and identify goals for the improvement of SBIRT model and MAUD application[61]. Interventions performed to facilitate brief intervention or MAUD use among healthcare practitioners in general hospitals and primary care facilities and to overcome barriers to such use improved the practitioners’ knowledge of the alcohol use-related intervention process and its integration into their daily workflow, and enhanced intervention intensity[62-64].

REFERRAL FOR ALCOHOL USE-RELATED PROBLEMS

For those with severe alcohol-related problems or AUD, brief interventions alone are inadequate to manage the consequences of alcohol use. Patients with AUDIT scores of 20-40 should be referred to specialists for diagnostic evaluation and treatment[23]. These individuals require more professional and structured intervention. Referral institutions and facilities include clinics and hospitals that provide more intensive specialty alcohol-related services, including specialized treatment programs, some of which are community based, and serve as community-based information sources[39,65]. Healthcare practitioners in general hospitals and primary care settings should provide information about referral protocols and facilities to patients[41].

The literature indicates that referral rates are quite low. Most participants in the SBIRT program initiated by the United States’ Substance Abuse and Mental Health Services Administration had had recent inpatient or ED experiences, and the proportions of referred patients in these two cohorts were 4.0% and 1.3%, respectively[66]. Theoretically, brief interventions can promote referral, as screening, intervention, and referral to treatment in general hospital and primary care settings are typically considered to promote patient recovery. However, findings regarding the impact of brief interventions on referral to treatment are inconclusive. A meta-analysis published in 2015 showed that brief interventions had no efficacy in terms of increasing the subsequent use of specialized alcohol-related service[67]. A regression analysis performed with data from the United States’ Veterans Health Administration and published in 2020 showed that individuals’ receipt of specialty treatment decreased following brief interventions overall, but tended to increase in some subgroups (e.g., individuals with no previous AUD diagnosis and repeated brief intervention receipt)[68]. Another study showed that brief interventions effectively increased treatment seeking among men[69]. Some randomized controlled trials have demonstrated the effectiveness of brief interventions with regard to referral to specialty alcohol-related treatment[65,70,71]. For example, the implementation of a SBIRT program in a general hospital in Denmark increased the percentage of patients attending specialized services, although the successful referral rate remained low (6%)[65].

Linkage between general hospitals/primary care facilities and specialized alcohol-related service providers is weak, and collaborative networks need to be strengthened. Many intervention “bricks” can be used to build a “bridge” leading to specialized treatment. First, access to such treatment needs to be increased, for example by providing sufficient referral resources, enhancing bidirectional communication between general hospitals/primary care facilities and referral centers, and increasing the affordability of the referral process[72]. Second, efforts can target specific subgroups. Third, the existing brief intervention model could be modified. For example, the embedding of a behavioral health clinician in a primary care setting may facilitate referral to specialty services[73]. Fourth, opportunities to enhance interventions after hospital discharge could be acted on[74]. In addition, research should be conducted to identify ways in which referral to treatment could be improved from policy, intervention model, patient, healthcare practitioner, and specialist perspectives.

ADVANTAGES AND DISADVANTAGES

The screening, interventions, and referral are essential for general hospitals and primary care settings to address alcohol-related problems. Meanwhile, when taking into practice, we should consider the advantages and disadvantages of the three dimensions described. Here we listed the advantages and disadvantages in Table 2.

Table 2 Advantages and disadvantages in three dimensions.

Dimensions	Advantages	Disadvantages
Screening	Broad use	Self-report tools
	Early detection	Lack of reliable objective markers
	Convenient
	Good validity
Intervention	Effectiveness in mild cases	Limited impact on severe AUD
	Flexibility	Cultural barriers
	Cost effective	Limited long-term impact
		Lack of training
Referral to treatment	Specialized care	Low referral rate and engagement
	Multidisciplinary support	Referral delay in practice

CONCLUSION

In summary, opportunities to prevent and manage alcohol-related problems in general hospitals and primary care settings are abundant. Various screening tools can be used in practice, and practitioners’ awareness of the need for screening should be strengthened. Although healthcare practitioners in these settings widely apply brief interventions for alcohol-related problems, the combination of these interventions with MAUD and CAM could improve the management of patients with severe problems under the framework of integrative medicine. Referral to treatment is somewhat ignored in these settings, and more interventions to promote specialized treatment for AUD should be developed. Screening, intervention, and referral to treatment form a continuum of response to patients’ alcohol-related problems of different severities. Step by step, practitioners in general hospitals and primary care settings can take advantage of the opportunities available to address this formidable public health issue.