Chun Wah Michael Tam
Louis Hion-Lam Leong
Alcohol-screening questionnaires have been found to be effective in the early detection of risky drinking but are rarely used by clinicians in primary care.
As research agenda tend not to seek the perspectives of patients and general practitioners (GPs), the best way to address the barriers to implementation is unclear. Contemporary research to explore patient beliefs and attitudes towards alcohol enquiry by GPs is needed.
General practitioners (GPs) are at the frontline in reducing the health burden of alcohol-related harms. Australian and international guidelines recommend a preventive approach – early detection of risky drinkers and providing brief interventions – and GPs are ideally placed as they have access to the at-risk population.1
Historically, few risky drinkers have been identified in general practice.2 Recognition of this phenomenon has led to the development of well-validated alcohol-screening questionnaires and policy promoting their use in routine care.1 The evidence supporting the use of some of these tools is substantial,3 yet the goal of early detection appears to be at an impasse.4,5 Few modern-day GPs use these alcohol-screening questionnaires,4 and even when they do, it might not be for the purpose of routine screening.5
What’s going on and how do we move forward? We believe what has occurred in the past provides relevant insights for the present.
A (very) brief history of alcohol-screening questionnaires
First described in 1970, one of the earliest and best-known alcohol-screening questionnaires is the CAGE questionnaire. It was designed to identify alcoholism but was later found to perform poorly in patients in the general population, compared with those in hospital.6
By the 1980s, the current paradigm of early intervention in alcohol misuse was firmly in place. There appeared to be a need for a new alcohol-screening questionnaire – one that could detect risky drinking, not just alcoholism, was suitable for use in primary healthcare and was valid in many cultural settings.6
A World Health Organization (WHO) collaborative project was formed to develop a new tool and the Alcohol Use Disorders Identification Test (AUDIT), a 10-question test, was developed.6 The AUDIT has since been extensively tested and validated in many international primary care contexts.3 Contemporaneous research into alcohol-screening questionnaires generally involves the AUDIT or a variant (eg AUDIT-C).
As researchers, it is impossible not to be impressed at the research methods used to develop the AUDIT. Remarkably, it involved almost 2000 patients from six countries (Australia, Bulgaria, Kenya, Mexico, Norway and the US). The questions were designed to be culturally neutral and the final questions were statistically determined to be the best from a number of conceptual domains, from an initial pool of 150.
What are GPs’ perspectives?
As clinicians, there was something in the narrative of the AUDIT’s creation that struck us as troubling. This tool was designed by alcohol researchers to be ‘suitable’ in primary healthcare, but ‘suitability’ seemed to have been based mostly on common-sense notions. Importantly, the perspectives of practitioners working in primary healthcare – those who would be asked to use the tool – were not sought during the design process. The inherent risk to such an approach was revealed when GPs who attempted to implement the AUDIT in their regular practice were asked about their experience. The AUDIT was found to interfere with the patient-centred approach and cause more problems than it solved. GPs could not recommend it even though they believed alcohol-use counselling was important.7
What are patients’ perspectives?
Patients are the recipients of these tools but little is known about their perspectives. We recently conducted a literature review on patient acceptability to receiving alcohol-use enquiry from GPs and, in summary, patients’ views were complex and unclear in the literature.8 GP involvement in health promotion was perceived by patients to be legitimate, but perhaps less so for alcohol than other topics, and alcohol enquiry might be unwelcome in specific consultations.8
We need to listen to patients’ and GPs’ perspectives
Alcohol-screening research is in the unenviable position of having created excellent psychometric screening tools but few of these are used in clinical practice. As the research agenda tend not to seek the perspectives of patients and GPs, we lack good explanations that are well grounded in evidence for this phenomenon. For instance, it appears patient–doctor consultation contexts are important,8 but which, how and why they are successful or unsuccessful remains unclear.
An immediate path forward is for research to explore patients’ beliefs and attitudes towards alcohol enquiry from their GPs. We need to better understand the situational factors of a consultation that improves the acceptability of these discussions. Early detection of risky drinking has enormous potential in general practice – we are in the right setting and GPs agree they have a role to play.5,7 Newer or updated alcohol-screening questionnaires are unlikely to be the answer on their own. Rather, we need to be equipped with strategies that can be practically implemented in our local contexts.
Declaration and acknowledgement
CT and NZ received the RACGP Family Medical Care, Education and Research Grant to fund a research project into understanding patient acceptability and attitudes to receiving alcohol-use enquiry from GPs. This article is part of that project and the authors gratefully acknowledge the RACGP Foundation for their support.
Competing interests: This article is based in part on activities that were part of the research project funded by the RACGP Foundation Family Medical Care, Education and Research Grant (2013).
Provenance and peer review: Not commissioned, externally peer reviewed.
- The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice, 8th edn. Melbourne: RACGP, 2012.
- Reid AL, Webb GR, Hennrikus D, Fahey PP, Sanson-Fisher RW. Detection of patients with high alcohol intake by general practitioners. BMJ 1986;293:735–37.
- Berner MM, Kriston L, Bentele M, Harter M. The alcohol use disorders identification test for detecting at-risk drinking: A systematic review and meta-analysis. J Stud Alcohol Drugs 2007;68:461–73.
- Khadjesari Z, Marston L, Petersen I, Nazareth I, Walters K. Alcohol consumption screening of newly-registered patients in primary care: A cross-sectional analysis. Br J Gen Pract 2013;63:e706–12.
- Tam CWM, Zwar N, Markham R. Australian general practitioner perceptions of the detection and screening of at-risk drinking, and the role of the AUDIT-C: a qualitative study. BMC Fam Pract 2013;14:121.
- Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption. Addiction 1993;88:791–804.
- Beich A, Gannik D, Malterud K. Screening and brief intervention for excessive alcohol use: Qualitative interview study of the experiences of general practitioners. BMJ 2002;325:870.
- Leong L, Tam CWM. Patient beliefs and attitudes towards the acceptability of receiving alcohol use enquiry from general practitioners: A literature review. PeerJ PrePrints 2014;2:e439v1.