Daniel W. Hungerford

Alcohol use prior to pregnancy recognition.

BACKGROUND Frequent alcohol use during the first 8 weeks of pregnancy can result in spontaneous abortion and dysmorphologic changes in the developing organ systems of the embryo, including the heart, kidneys, and brain. However, few population-based studies are available that describe the prevalence of frequent drinking (6 or more drinks per week) among women prior to and during early pregnancy (the periconceptional period), and the sociodemographic and behavioral factors that characterize these women. Such knowledge is fundamental to the design of targeted interventions for the prevention of fetal alcohol syndrome (FAS) and other prenatal alcohol-related disorders. METHODS This cross-sectional study used survey data collected by the National Center for Health Statistics as part of the 1988 National Maternal and Infant Health Survey (NMIHS). Weighted prevalence estimates were calculated using SUDAAN, and multivariate analyses were used to determine risk factors for frequent drinking. RESULTS Forty-five percent of all women surveyed reported consuming alcohol during the 3 months before finding out they were pregnant, and 5% reported consuming 6 or more drinks per week. Sixty percent of women who reported alcohol consumption also reported that they did not learn they were pregnant until after the fourth week of gestation. Risk factors for frequent drinking during the periconceptional period included 1 or more of the following: being unmarried, being a smoker, being white non-Hispanic, being 25 years of age or older, or being college educated. CONCLUSIONS Half of all pregnant women in this study drank alcohol during the 3 months preceding pregnancy recognition, with 1 in 20 drinking at moderate to heavy levels. The majority did not know they were pregnant until after the fourth week of pregnancy, and many did not know until after the 6th week. Alcohol is a teratogen capable of producing a number of adverse reproductive and infant outcomes. Public health measures needed to reduce these potentially harmful exposures include alcohol assessment, education, and counseling for women of childbearing age, with referral sources for problem drinking, and family planning services for pregnancy postponement until problem drinking is resolved.

Gestational weight gain among average-weight and overweight women — What is excessive?

OBJECTIVE Our purpose was to determine the association between increased gestational weight gain and birth weight outcomes for low-income women. STUDY DESIGN A total of 53,541 single, live infants delivered from 1990 to 1991 to white, black, and Hispanic women in eight states were evaluated. Multiple logistic regression was used to calculate risk of low and high (> 4500 gm) birth weight, adjusting for selected factors. RESULTS The association between gestational weight gain and birth weight varied by prepregnancy body mass index. Risk for low birth weight decreased with increasing weight gain for average-weight women. There was no reduction in risk for low birth weight, however, beyond weight gains of 30 to 34 pounds for overweight women and 15 to 19 pounds for very-overweight women. Risk for high birth weight, however, increased with increasing weight gain in all three groups. CONCLUSION Very-overweight women (body mass index > 29 kg/m2) may benefit from an upper guideline of 25 pounds of weight gain to help reduce risk for high birth weight.

Screening and brief intervention for alcohol problems among college students treated in a university hospital emergency department.

Abstract The authors evaluated a protocol to screen and provide brief interventions for alcohol problems to college students treated at a university hospital emergency department (ED). Of 2,372 drinkers they approached, 87% gave informed consent. Of those, 54% screened positive for alcohol problems (Alcohol Use Disorders Identification Test score < 6). One half to two thirds of the students who screened positive drank 2 to 3 times a week, drank 7 or more drinks per typical drinking day, or had experienced alcohol dependence symptoms within the past year. Ninety-six percent of screen-positive students accepted counseling during their ED visit. Three quarters of those questioned at 3-month follow-up reported that counseling had been helpful and that they had decreased their alcohol consumption. The prevalence of alcohol problems, high rates of informed consent and acceptance of counseling, and improved outcomes suggest that the ED is an appropriate venue for engaging students at high risk for alcohol problems.

Screening and brief intervention for substance misuse among patients with traumatic brain injury.

BACKGROUND Research on screening and brief interventions (SBI) for substance misuse has demonstrated efficacy in a variety of medical settings including emergency departments and trauma centers. However, SBI has not yet been evaluated for persons who incur traumatic brain injury (TBI)-a substantial patient subpopulation for whom substance-related problems are frequent. To examine whether research on SBI efficacy and effectiveness can be generalized to persons with TBI, a systematic review of the literature was conducted to analyze how TBI populations were included in previous studies and whether there was evidence of differential outcomes. METHODS Peer-reviewed studies that investigated SBI for misuse of alcohol or other drugs, that were implemented in emergency departments or trauma centers, and that were published in English since 1985 were examined. From 174 articles initially identified, 28 studies were determined to meet inclusion criteria. RESULTS The review revealed that research conducted on SBI for injury populations systematically neglected patients with more severe TBI and those who presented with sufficient confusion that they could not provide informed consent. CONCLUSIONS Future effectiveness studies should examine barriers to routine clinical use of SBI and evaluate the generalizability of expected benefits to the full spectrum of injured patients. Researchers should also develop and evaluate systematic accommodations for persons with neurobehavioral impairments who would benefit from brief interventions for substance misuse.

Emergency department visits for alcohol-related unintentional traumatic injuries, United States, 2001

The single greatest contributor to alcohol-related mortality in the United States is unintentional injury, accounting for approximately 26,000 deaths per year and placing a substantial burden on emergency departments (EDs). This study analyzes 2001 data from a nationally representative sample of hospital EDs to examine characteristics of ED visits for alcohol-related unintentional traumatic injuries and compared them with visits for unintentional traumatic injuries for which alcohol use was not noted in the ED medical chart. This study presents the first estimate of annual ED visits for alcohol-related traumatic injuries due only to unintentional causes; previous estimates have included injuries from all causes. The results indicate that in 2001 an estimated 314,304 patients were treated in EDs for alcohol-related unintentional traumatic injuries (ARVs). Compared with visits for unintentional traumatic injuries for which alcohol use was not noted in the ED medical chart, ARVs were more likely to involve injuries that require extensive health care services such as falls, motor-vehicle injuries, internal injuries, and brain injuries. The more serious nature of ARVs was also demonstrated by a four-fold higher hospitalization rate compared with non-ARVs.

Alcohol Electronic Screening and Brief Intervention: A Community Guide Systematic Review

CONTEXT Excessive drinking is responsible for one in ten deaths among working-age adults in the U.S. annually. Alcohol screening and brief intervention is an effective but underutilized intervention for reducing excessive drinking among adults. Electronic screening and brief intervention (e-SBI) uses electronic devices to deliver key elements of alcohol screening and brief intervention, with the potential to expand population reach. EVIDENCE ACQUISITION Using Community Guide methods, a systematic review of the scientific literature on the effectiveness of e-SBI for reducing excessive alcohol consumption and related harms was conducted. The search covered studies published from 1967 to October 2011. A total of 31 studies with 36 study arms met quality criteria and were included in the review. Analyses were conducted in 2012. EVIDENCE SYNTHESIS Twenty-four studies (28 study arms) provided results for excessive drinkers only and seven studies (eight study arms) reported results for all drinkers. Nearly all studies found that e-SBI reduced excessive alcohol consumption and related harms: nine study arms reported a median 23.9% reduction in binge-drinking intensity (maximum drinks/binge episode) and nine study arms reported a median 16.5% reduction in binge-drinking frequency. Reductions in drinking measures were sustained for up to 12 months. CONCLUSIONS According to Community Guide rules of evidence, e-SBI is an effective method for reducing excessive alcohol consumption and related harms among intervention participants. Implementation of e-SBI could complement population-level strategies previously recommended by the Community Preventive Services Task Force for reducing excessive drinking (e.g., increasing alcohol taxes and regulating alcohol outlet density).

Self-Reported Prevalence of Alcohol Screening Among U.S. Adults

INTRODUCTION The U.S. Preventive Services Task Force recommends for adults alcohol screening and brief behavioral counseling interventions in primary care settings. However, there is a paucity of population-based data on the prevalence of alcohol screening. This study examines adherence to this U.S. Preventive Services Task Force recommendation by estimating the prevalence of alcohol screening by demographic characteristics and binge drinking. METHODS A cross-sectional analysis was conducted in 2013 and 2014 on data from the 2013 fall wave of the ConsumerStyles survey. ConsumerStyles is drawn from an Internet panel randomly recruited by probability-based sampling to be representative of the U.S. POPULATION Data from 2,592 adult respondents who visited primary care physicians in the last year were analyzed to determine the prevalence of alcohol screening. RESULTS Only 24.7% of respondents reported receiving alcohol screening. The prevalence of screening was similar among women (24.9%) and men (24.5%). Black non-Hispanics reported a significantly lower prevalence of screening than white non-Hispanics (16.2% vs 26.9%, prevalence ratio=0.60, 95% CI=0.40, 0.90). College graduates reported a significantly higher prevalence of screening than respondents with a high school degree or less (28.1% vs 20.8%, prevalence ratio=1.35, 95% CI=1.08, 1.69). CONCLUSIONS Only about one in four respondents who visited a primary care physician in the last year reported being screened for alcohol misuse. Therefore, many men and women who misuse alcohol are unlikely to be identified. Increased screening may help reduce alcohol misuse and related negative health outcomes.

Alcohol Screening and Brief Intervention: A Potential Role in Cancer Prevention for Young Adults

Excessive or risky alcohol use is a preventable cause of significant morbidity and mortality in the U.S. and worldwide. Alcohol use is a common preventable cancer risk factor among young adults; it is associated with increased risk of developing at least six types of cancer. Alcohol consumed during early adulthood may pose a higher risk of female breast cancer than alcohol consumed later in life. Reducing alcohol use may help prevent cancer. Alcohol misuse screening and brief counseling or intervention (also called alcohol screening and brief intervention among other designations) is known to reduce excessive alcohol use, and the U.S. Preventive Services Task Force recommends that it be implemented for all adults aged ≥ 18 years in primary healthcare settings. Because the prevalence of excessive alcohol use, particularly binge drinking, peaks among young adults, this time of life may present a unique window of opportunity to talk about the cancer risk associated with alcohol use and how to reduce that risk by reducing excessive drinking or misuse. This article briefly describes alcohol screening and brief intervention, including the Centers for Disease Control and Prevention’s recommended approach, and suggests a role for it in the context of cancer prevention. The article also briefly discusses how the Centers for Disease Control and Prevention is working to make alcohol screening and brief intervention a routine element of health care in all primary care settings to identify and help young adults who drink too much.

Alcohol interventions in emergency medicine: referral makes a difference.

In this week’s Lancet, Mike Crawford and colleagues report that a group of patients in the emergency department (ED) who were referred to an alcohol-health worker had lower alcohol consumption and fewer revisits to the ED at followup than a group not referred. Also, the subset of referred patients who kept their appointment with the alcohol-health worker drank less than those who did not keep their appointment, although this result was not statistically significant. These findings provide evidence for the efficacy of point-ofcare referrals for ED patients with alcohol problems. The measured effects suggest the simple act of referring a patient with alcohol problems for further treatment might itself have preventive benefits. A physician-prescribed follow-up visit to an alcohol-health worker underscored concern about the patient’s drinking behaviour. In effect, referral was an intervention. Conversely, the absence of a physicianarranged appointment for control patients might have attenuated the influence of other messages in the ED about alcohol problems. In effect, a health-information leaflet was not as powerful as direct communication with a physician about the need for follow-up after the ED visit. The findings reported by Crawford and colleagues raise the question of why the visit to the alcohol-health worker was associated with drinking less, a benefit that was not statistically significant. A possible explanation is that the sample size was too small. Alternatively, the benefit does not exist. Yet another possibility is that the group who kept the appointment had more severe alcohol problems, so the effect of the visit was smaller or non-existent. The findings also raise the question of what comprises a clinically significant benefit for alcohol problems. At 6 months, those who kept their appointment with an alcohol-health worker were drinking 60 units of alcohol a week, which is excessive. Nonetheless, such use might be substantially below baseline consumption. Unfortunately, comparisons with alcohol consumption at baseline are not possible because these data were not collected. For an efficacy trial, this was a major methodological limitation. Without these data, we cannot fully evaluate individual response to the intervention. There is also the possibility that differences in group consumption documented at follow-up also existed at baseline. Crawford and colleagues attempt to allay concerns about this potential selection bias by presenting the similarities in available baseline data for patients followed up or not. Although analyses based on individuallevel baseline data would have addressed this issue more conclusively, it may be less of a shortcoming in a pragmatic trial.

Screening for Alcohol Misuse: Practices Among U.S. Primary Care Providers, DocStyles 2016

INTRODUCTION Excessive alcohol use is associated with car crashes, violence, and multiple disease conditions, including fetal alcohol spectrum disorders. The U.S. Preventive Services Task Force (USPSTF) recommends that primary care providers screen all adults and conduct brief counseling interventions with those who misuse alcohol. The USPSTF prefers use of three screening tools that measure alcohol consumption (Alcohol Use Disorders Identification Test, Alcohol Use Disorders Identification Test-Consumption, and National Institute on Alcohol Abuse and Alcoholism Single Question) because these tools detect the full spectrum of alcohol misuse in adults. This study estimated the prevalence of primary care provider screening practices for alcohol misuse and examined factors associated with using a USPSTF-preferred screening tool. METHODS In 2016, a cross-sectional analysis was conducted on self-reported 2016 DocStyles data to estimate the prevalence of different screening tools used by 1,506 primary care providers-family practitioners, internists, obstetrician/gynecologists, and nurse practitioners. Adjusted prevalence ratios were calculated using logistic regression to examine the association between provider attributes and use of USPSTF-preferred screening tools. RESULTS In this study, 96% of providers reported screening patients for alcohol misuse. Among those that screened, 38% used a USPSTF-preferred screening tool. Provider specialty, awareness of USPSTF guidelines, and mode of administering screening tool were associated with using a preferred screening tool. CONCLUSIONS Although most primary care providers reported screening for alcohol misuse, about two thirds did not use a tool capable of detecting the full spectrum of alcohol misuse. Using suitable screening tools will better identify patients who misuse alcohol and increase the opportunity for appropriate intervention, ultimately helping to reduce the burden from the many conditions associated with excessive alcohol consumption.