Problem Drinking Numbers Alarming

Alcohol consumption is on the rise in Canada. A new guideline just published in CMAJ(sorry for the paywall) says doctors must do more to screen patients at risk of problem drinking.

Health Canada defines at risk or problem drinking as consumption that exceeds the Canadian guidelines for low risk drinking. For men, the level above which you exceed low risk drinking is fifteen standard drinks per week with no more than three drinks a day on most days. One standard drink equals a 341 ml or a 12 ounce bottle of 5% beer, cider or cooler, a 43 ml or 1.5 ounce shot of 40% hard liquor, or a 142 ml or 5oz glass of 12% wine. Fifteen standard drinks a week for men, but only ten standard drinks a week and no more than two standard drinks a day for women.

You may have noticed that the threshold for problem drinking in women lower than it is in men. There are good physiological reasons for this.The National Institute on Alcohol Abuse and Alcoholism says women start to have alcohol-related problems at lower drinking levels than men do. One reason is that, on average, women weigh less than men. In addition, the alcohol you drink resides mainly in the body's water. Kilogram for kilogram, women have less water in their bodies than men do. So if a man and woman of the same weight drink the same amount of alcohol, the woman's blood alcohol level will be higher, putting her at greater risk for harm. Other biological differences, including hormones, may contribute as well.

it's important to emphasize thatproblem drinking is not the same as meeting the criteria for an alcohol use or dependence disorder. Still, problem drinking increases the risk of a broad range of health problems later in life, such as cancer, heart disease, and liver disease.

To stem the tide of problem drinking, thearticle in CMAJ - authored by experts from the US - calls on doctors, nurse practitioners and other health providers to screen all patients for problem drinking. That means asking every patient about their weekly and their daily consumption of alcohol. If a pattern of problem drinking is identified, the new guideline recommends that we offer counselling and feedback using the FRAMES approach. FRAMES is an acronym. F means feedback of the risk of drinking. R means responsibility to cut down on drinking. A means giving advice, M means giving a menu of treatment options, E means empathy, and S means self-efficacy. The key is that the approach is made, and it doesn't have to be time consuming. It can range from less than five minutes with no follow through on up to several sessions of up to fifteen minutes in length.

Analyses of fifty-six individual studies show that a brief intervention delivered by a family doctor, GP, nurse practitioner or other primary care provider that uses the FRAMES approach is effective in reducing potentially harmful drinking. Weekly alcohol consumption goes down on average by thirty-eight grams or just under three standard drinks a week. There are a few caveats to these studies. They address people who exceed safe drinking levels - not those who meet the criteria for alcohol abuse disorder. There is mixed evidence that this approach works as well in women as it does in men. It doesn't work particularly well in pregnant women, which is odd considering the societal pressure on women not to drink if they plan on getting pregnant. There are also concerns about the long-term benefit of brief interventions.

Beyond the things that health care providers shoulddo on an individual level, the system has to change. An accompanying commentary in CMAJ says that as is, the system provides inadequate access to effective treatment for at risk drinking and alcohol use disorders. It says physicians and other providers need better training. While it's tempting to call for more alcohol treatment specialists, the article notes that patients often fail to show up for specialist appointments. The focus should remain on getting family doctors and nurse practitioners up to speed. The article also says authorities should make prescription medications like naltrexone and acamprosate more available to patients at risk.

I think this is an important guideline. But I worry that primary care providers lack the time and the skill to raise these important issues with patients. I hope I'm wrong.