Unhealthy alcohol use screening and counseling
Recommendations
USPSTF2018Grade B
Screen all adults 18 and older, including pregnant persons, for unhealthy alcohol use in primary care; provide brief behavioral counseling to those with risky or hazardous drinking. Use validated 1 to 3 item tools (AUDIT-C or single-question NIAAA screen). Adolescents 12 to 17: insufficient evidence (I).
Verify at USPSTF (opens in a new tab)APA2018Grade 1B (naltrexone, acamprosate); 2C (others)
Moderate to severe alcohol use disorder: offer naltrexone or acamprosate to patients who want to cut down or abstain, prefer medication or have not responded to nondrug treatment alone, and have no contraindications. Disulfiram (abstinence goal only) or topiramate or gabapentin are options when the patient prefers them or has not tolerated or responded to naltrexone and acamprosate. Avoid naltrexone with acute hepatitis, liver failure, or current or expected opioid use; avoid acamprosate in severe renal impairment.
Verify at APA (opens in a new tab)Who this applies to
- All adults 18 and older in primary care, including during pregnancy (USPSTF 2018, Grade B). Adolescents: insufficient evidence (I).
How it is done in practice
- Single question (NIAAA): how many times in the past year have you had 5 or more drinks in a day (men) or 4 or more (women, and all adults over 65)? Any answer above zero is positive. AUDIT-C (3 items) is positive at 4 or more in men and 3 or more in women; the full 10-item AUDIT grades severity, with 8 or more suggesting hazardous or harmful use.
- Risky drinking (NIAAA): men, more than 4 drinks in a day or 14 in a week; women, and everyone 65 and older, more than 3 in a day or 7 in a week. A standard drink is 14 g of alcohol: 12 oz of 5 percent beer, 5 oz of wine, or 1.5 oz of spirits.
- Brief intervention: usually one to four short sessions (a median of about 30 minutes of total contact in the trials USPSTF reviewed), with personalized feedback and a goal. It reduces weekly drinking in risky drinkers. It is not the treatment for alcohol use disorder.
- Alcohol use disorder (DSM-5, 2 or more criteria in a year; 4 or more is moderate to severe): for moderate to severe disorder, offer naltrexone or acamprosate first line, with disulfiram, topiramate or gabapentin when those are not tolerated or not working, or the patient prefers them (APA 2018), plus counseling or mutual support. Assess withdrawal risk before any abrupt stop.
What changed recently
The 2018 update widened the target from alcohol misuse to unhealthy use, covering the whole spectrum from risky drinking to dependence, and endorsed brief 1 to 3 item screens. The CAGE questionnaire detects dependence and misses risky drinking, so it no longer fits the task.
Points that matter in clinic
- Pregnancy: there is no safe amount. Screen at the first prenatal visit and each trimester.
- Naltrexone needs no detox first: 50 mg daily or a monthly injection. Avoid it in anyone using or expecting to need opioids, and in acute hepatitis or liver failure. Acamprosate is the choice in liver disease but not in severe kidney impairment. GGT, MCV and phosphatidylethanol (PEth) give objective follow-up.
- Fewer than 1 in 10 people with alcohol use disorder ever receive a medication for it. Prescribing in primary care is where that gap closes.