Excessive alcohol use is among the leading cause of morbidity and premature death in the United States. Too much drinking causes chronic conditions like alcoholic liver disease and predisposes individuals to injuries caused by accidents. Additionally, alcohol use during pregnancy is one of the major preventable causes of developmental disabilities and birth defects. Screening and brief behavioral counseling interventions are recommended to address the challenge of unhealthy alcohol use (UAU) among adolescents and adults. The most commonly used screening tools include Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) and the NIAAA-recommended Single Alcohol Screening Question (SASQ). despite the availability of these tools, alcohol use is still a major problem, especially among the elderly. This discussion presents evidence from qualitative and quantitative research regarding the use of screening to address unhealthy alcohol use.
This section describes findings from 10 primary research articles focusing on unhealthy alcohol use screening. All ten articles support the intervention of using the AUDIT screening tool to improve behavioral counseling referrals. A total of four Level I and six Level III articles were identified during the literature search. Regarding the aspect of article quality, one was of high quality (A), three were of good quality (B), and six represented evidence with both high and good quality. Alcohol Use Screening Guidelines
Clinical strategies to reduce excessive alcohol use have focused on screening and brief intervention based on the recommendations from practice guidelines. For instance, the United States Preventive Services Taskforce (USPSTF) recommends effective measures for unhealthy alcohol use for adults. Based on recent data, screening for unhealthy alcohol use in primary care settings should be done for adults aged 18 years and older. Additionally, screened individuals should be provided with brief behavioral counseling interventions to reduce unhealthy alcohol use (USPSTF, 2018). for adolescents aged 12 to 17 years, the effectiveness of screening and behavioral counseling lacks sufficient evidence. These recommendations are consistent with the Centers for Disease Control and Prevention (CDC) guidelines that find screening to positively impact drinking aspects like binge drinking. There is also an emphasis on the use of electronic devices like computers and telephones to guide screening and brief interventions (CDC, 2022). These devices ensure the delivery of personalized feedback and offer advice designed to reduce excessive drinking.
Improving UAU Screening in Primary Care
The societal and health consequences of unhealthy alcohol use are well-known and continue to worsen. In the United States, unhealthy alcohol drinking contributes to more than 95000 deaths annually and many are left with huge hospital bills following injuries (Singh et al., 2022). There is adequate evidence that primary care facilities lack support to effectively implement screening and treatment of individuals with alcohol use problems. For example, Screening, brief intervention, and referral to treatment (SBIRT) is a clinical process that uses validated screening tools to manage unhealthy alcohol intake. Poor implementation of this strategy in primary care has contributed to poor diagnosis and referral of patients for special care. For instance, surveillance data shows that only 37.8% of adults remember being asked about binge drinking during their last check-up(Singh et al., 2022). these findings indicate that screening should be well-supported by clear organizational policies and preparedness or rather willingness of providers to help affected individuals.
Unhealthy alcohol use involves a spectrum from drinking exceeding guidelines to alcohol dependence. The continuity of quality improvement in healthcare requires the implementation of strategies to detect and manage alcohol abuse. Research conducted to identify strategies to improve implementation of screening identified data-guided activities, considering alcohol conditions, and iterative development as the main points. This research also observed that the provision of referral services away from primary healthcare facilities can greatly help to manage unhealthy alcohol drinking (Dzidowska et al., 2020). To improve screening and treatment uptake in primary care facilities, addressing barriers that cause inefficiencies in problem identification and counseling is required.
Understanding the patient’s perspective on using screening to manage unhealthy alcohol use is critical in healthcare. The challenges that clinicians experience when providing services are well-known, but the patient’s perspective remains uncertain. Research conducted to explore the patients’ views on alcohol screening and brief advice revealed that screening is effective and promotes engagement with clinicians (O’Donnell, 2020). The rate and scale of implementation of screening services are dependent on the patient’s level of knowledge, beliefs, and social-political context. Most importantly, the researchers observed that screening alone does not yield better results because most patients learn self-regulatory techniques through experience. Most patients saw alcohol advice as a valuable component of preventive healthcare and more effort should be put to ensure timely referral of patients after screening.
AUDIT Screening Tool
Unhealthy alcohol use is relatively common and is estimated to be the third leading cause of death in the US. Reports from early 2000 indicate that unhealthy drinking accounts for 9.8% of all deaths. Approximately 26% of adults and 4.9% of adolescents reported heavy drinking in 2016 and these numbers have since increased (O’Connor et al., 2018). Unhealthy drinking has best been managed by early detection and behavioral counseling in primary care facilities. The use of screening tools like the Alcohol Use Disorders Identification Test (AUDIT) and Single Alcohol Screening Question (SASQ) make it easy for practitioners to detect unhealthy drinking. Evidence indicates that screening with these tools has a positive effect on affected individuals and helps to guide further treatment of severely affected patients (O’Connor et al., 2018). Consequently, behavioral counseling that results from screening is positively associated with a reduction in unhealthy alcohol use.
Certain factors like economic status, social environment, and individual characteristics affect the direction of screening services in healthcare (Wolf et al., 2019). For example, patients with past year frequency and heavier drinking context should receive special attention compared to the rest of the population. Likewise, those from dysfunctional families and mental illnesses like depression should receive special attention. In research to identify drinking contexts in which prevention efforts should be directed, physiological problems were more associated with frequent drinking. For example, conflict was associated with more frequent drinking making behavioral interventions after screening a crucial aspect of the treatment process (Wolf et al., 2019). Identifying which drinking contexts are associated with specific alcohol-related problems is an essential component of guiding screening and other preventive interventions.
Barriers to AUDIT Implementation
Alcohol screening and brief interventions (ASBI) is a strategy aimed at addressing the rise in alcohol-related ill health. When applied to part of routine screening using AUDIT and other tools, preventive services can be effective in reducing risky drinking. Various barriers to screening and behavioral interventions are identified to hinder unhealthy alcohol use control. For example, there is sufficient evidence that lack of skills and knowledge in implementing interventions, attitudes to alcohol use by health professionals, and uncertainty of screening effectiveness in community settings impair the achievement of results (Derges et al., 2017). Perhaps, addressing these barriers can improve results observed in primary care concerning alcohol use screening. More strategies like the utilization of local governments, social services, and private agencies are proposed to address these challenges, especially among adolescents (Derges et al., 2017). Improving how health service institutions respond to and coordinate alcohol services can be an important step toward better implementation of ASBI.
Healthcare providers experience challenges during the screening process for alcohol use disorder making the practice difficult to implement. Most general practitioners report that they do not screen for alcohol use disorders because of poor relationships with patients. The questions that must be asked of all adults are viewed as a disturbance in a relationship built on mutual trust (Coste et al., 2020). Lack of time due to an influx of patients in primary care facilities and poor training contribute to the alcohol use screening challenges observed. In France, evidence suggests that only 23% of general practitioners screen for excessive alcohol use. In another study, the level of education is observed to impact the patient’s understanding and response during screening. Those with a higher level of education are observed to have lower levels of consumption and indicators of unhealthy alcohol use (Bertholet et al., 2019). To effectively implement screening and brief behavioral interventions, healthcare facilities should consider how other factors like education level and training of providers impact this process.
Centers for Disease Control and Prevention. (2022). Cancer: Clinical strategies to reduce excessive alcohol use. https://www.cdc.gov/cancer/alcohol/reducing-excessive-alcohol-use/clinical-strategies.htm
Coste, S., Gimenez, L., Comes, A., Abdelnour, X., Dupouy, J., & Escourrou, E. (2020). Discussing alcohol use with the GP: A qualitative study. BJGP Open, 4(2), bjgpopen20X101029. https://doi.org/10.3399/bjgpopen20X101029
Bertholet, N., Daeppen, J. B., Studer, J., Williams, E. C., Cunningham, J. A., Gmel, G., & Burnand, B. (2020). A randomized trial of brief web-based prevention of unhealthy alcohol use: Participant self-selection compared to a male young adult source population. Internet Interventions, 19, 100298.
Derges, J., Kidger, J., Fox, F., Campbell, R., Kaner, E., & Hickman, M. (2017). Alcohol screening and brief interventions for adults and young people in health and community-based settings: A qualitative systematic literature review. BMC Public Health, 17(1), 562. https://doi.org/10.1186/s12889-017-4476-4
Dzidowska, M., Lee, K. S., Wylie, C., Bailie, J., Percival, N., Conigrave, J. H., … & Conigrave, K. M. (2020). A systematic review of approaches to improve practice, detection and treatment of unhealthy alcohol use in primary health care: A role for continuous quality improvement. BMC Family Practice, 21(1), 1-22.
O’Connor, E. A., Perdue, L. A., Senger, C. A., Rushkin, M., Patnode, C. D., Bean, S. I., & Jonas, D. E. (2018). Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: Updated evidence report and systematic review for the US Preventive Services Task Force. Jama, 320(18), 1910-1928. https://pubmed.ncbi.nlm.nih.gov/30525341/
O’Donnell, A., Hanratty, B., Schulte, B., & Kaner, E. (2020). Patients’ experiences of alcohol screening and advice in primary care: A qualitative study. BMC family practice, 21(1), 1-11. https://doi.org/10.1186/s12875-020-01142-9
Singh, A. N., Sanchez, V., Kenzie, E. S., Sullivan, E., McCormack, J. L., Hiebert Larson, J., … & Davis, M. M. (2022). Improving screening, treatment, and intervention for unhealthy alcohol use in primary care through clinic, practice-based research network, and health plan partnerships: Protocol of the ANTECEDENT study. PloS One, 17(6), e0269635. https://doi.org/10.1371/journal.pone.0269635
US Preventive Services Task Force. (2018). Final recommendation statement: Unhealthy alcohol use in adolescents and adults: Screening and behavioral counseling interventions. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/unhealthy-alcohol-use-in-adolescents-and-adults-screening-and-behavioral-counseling-interventions
Wolf, J. P., Lipperman-Kreda, S., & Bersamin, M. (2019). “It just depends on the environment”: Patterns and decisions of substance use and co-use by adolescents. Journal of Child & Adolescent Substance Abuse, 28(3), 143–149. https://doi.org/10.1080/1067828x.2019.1637316
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