Do You Ask Whether Your Patient Drinks?

About 74% of Brazilian adults reported not having consumed an alcoholic beverage in the previous 30 days in a recent survey.

The 2019 Brazilian National Health Survey (PNS), a national household survey conducted by the Brazilian Ministry of Health in partnership with the Brazilian Institute of Geography and Statistics, is the largest national survey of its kind. It included, among other things, a questionnaire on alcohol consumption, to which 87,555 adults responded.

The responses show that most men (62.7%) and women (82.9%) were nondrinkers. The information was collected in a face-to-face interview, and alcohol consumption was self-reported.

According to the 2019 PNS, those who reported never drinking or drinking less than once in the past month were considered “nondrinkers.” One drink unit (that is, one can of beer, one glass of wine, or one distilled drink, such as cachaça or whiskey) was calculated as containing 12.5 g of alcohol. The investigators established the following categories: nondrinkers (0 g/day), light drinkers (1.0 to 12.5 g/day), moderate drinkers (12.6 to 49.9 g/day), and heavy drinkers (≥50 g/day).

Higher Education, Higher Consumption

In total, approximately 26.5% of the Brazilian population who were interviewed were drinkers; they reported having consumed alcoholic beverages in the 30 days before the survey. Most of the drinkers were aged 25 to 44 years. Among the self-declared drinkers, consumption of alcohol was higher among unmarried men. Being single, divorced, or separated was a strong predictor of hazardous alcohol consumption.

Having higher educational attainment was associated with increased alcohol consumption. Among men with no or incomplete primary education at the time of the interview, 70.2% reported that they did not consume alcohol. Among those who graduated from college, only 52.1% said that they had not consumed alcoholic beverages in the 30 days prior to taking the survey. Among women, the tendency was similar: 90.8% and 72.6%, respectively.

The tendency to consume alcohol was higher among White participants than non-White participants. Black women, who were 38% more likely to be moderate drinkers than White women, were an exception. Regarding distribution by state, the highest consumption of alcohol was found in Sergipe and Mato Grosso for men and Mato Grosso do Sul and Bahia for women.

Among men, the prevalence of light drinkers was 18.1%, followed by 16.0% for moderate drinkers and 3.2% for heavy drinkers. Among women, the situation was different: the prevalence was 11.9% for light drinkers, 4.6% for moderate drinkers, and 0.6% for heavy drinkers.

Women older than 55 years and men older than 65 years were less likely to be drinkers.

Identifying Alcohol-Related Problems

“It’s reassuring to learn that 70% of people from low income and low educational backgrounds do not drink. However, among those that do, 3% are dependent, and 10% drink dangerously…. This is a very high percentage. If we took the city of Rio de Janeiro as an example, we would be talking about 400,000 people,” Sandra Fortes, MD, PhD, psychiatrist and associate professor at the State University of Rio de Janeiro School of Medical Sciences, told Medscape Medical News. “Despite these numbers, in primary care, [healthcare professionals] do not ask patients about their alcohol consumption.”

Fortes is the coordinator of the Interdisciplinary Research Laboratory for Primary Health Care, in Rio de Janeiro. She also coordinates the study on training for problematic alcohol consumption in primary care. She has worked in partnership with the City University of New York for 20 years.

Fortes has come to realize that one of the most fundamental issues of primary care in Brazil is that problems of alcohol consumption are not treated. “But rates of alcohol consumption are high. There are several studies showing that 10% of the adult population has a problem with harmful [alcohol] use or is dependent [on alcohol],” she explained.

One of the team’s objectives is to develop training for nonspecialist clinicians and nurses who, with support from mental health specialists, can identify patients’ alcohol consumption and talk to them about it.

The group recently conducted a study in Rio de Janeiro on the perception of healthcare professionals regarding patients’ harmful alcohol use. The study showed that the clinicians and nurses who were interviewed rarely identified problems related to alcohol among their patients. Problems were observed only when severe or obvious problems had already manifested. Alcohol use was often viewed as a simple coping strategy. In general, the clinicians and nurses interviewed did not view light to moderate drinking as harmful. One of the conclusions to be drawn is that healthcare professionals do not prioritize alcohol screening because drinking is seen as socially acceptable.

“Why don’t primary care providers ask about alcohol consumption? Because it is often seen as a lifestyle choice and not a health issue,” said Fortes.

According to Fortes, this shortfall in medical training in not conducting alcohol screening is rooted in clinicians’ graduate education. “However, every clinician should ask about alcohol consumption, talk to the patient about their drinking habits, and, if harmful use or dependence is noted, nonspecialist clinicians must request specialist support.

“‘Social alcohol consumption’ and ‘alcoholism’ are terms that should be scrapped. Healthcare professionals should feel confident about asking patients directly, ‘Do you drink?’ And if the answer is ‘yes,’ they should ask the patient about their alcohol consumption in an objective way.

“Clinicians cannot hide behind vague concepts, such as drinking socially or alcoholism. The term ‘social drinking’ should be removed from the patient medical history form because it does not provide any specific information. There is a stigma associated with alcoholism, and it is not a true diagnosis.”

Regular Screening Recommended

Fortes recommends that clinicians apply the Alcohol Use Disorders Identification Test (AUDIT), which shows the true level of risk, if they feel comfortable enough to do so. The AUDIT is an assessment tool recognized by the World Health Organization. It is a simple method to screen for problems connected to alcohol consumption in primary care services. The test has been adapted and validated for Brazil.

AUDIT asks 10 questions. The score helps identify four patterns of consumption: low-risk drinking or abstinence (consumption will most likely not lead to problems), hazardous drinking (consumption may lead to problems), harmful drinking (consumption has likely already led to problems), and possible alcohol dependence. Specialists use the term “problematic use” for the latter three patterns of consumption.

Even if this tool is not used, clinicians should gather information on patients’ level of alcohol consumption. Fortes explains that on the basis of current evidence, any alcohol consumption can be harmful. However, clinicians may tell patients that up to 7 units per week (for women) or 14 units per week (for men), when limited to 3 or 4 units, respectively, per social occasion, are associated with a lower risk.

Not asking certain questions about alcohol consumption can exacerbate other physical or mental health disorders. On the other hand, early detection of cases and brief intervention can reduce harmful alcohol use and associated problems. Low detection rates can center the problem on a small number of individuals in whom harmful alcohol consumption is easily identified, but this hides a problem among a larger patient population.

“The lack of regular screening contradicts the emphasis from the Brazilian National Health System’s primary care system. There is a missed opportunity to detect harmful alcohol use before problems become more severe,” the study authors report.

They believe that the next generation of healthcare professionals will be fundamental in increasing the early detection of alcohol-related problems. Integrating the subject of alcohol into medical and nursing curricula and teaching students to use a standardized screening tool must become a part of medical education. And they have a further suggestion: “Teaching can include how to monitor alcohol use for changes over time, similarly to how weight and blood pressure changes are monitored.”

Fortes has disclosed no relevant financial relationships.

Roxana Tabakman is a biologist, freelance reporter, and writer who resides in São Paulo, Brazil. She is the author of the books A Saúde na Mídia, Medicina para Jornalistas, Jornalismo para Médicos (in Portuguese), and Biovigilados (in Spanish). Follow her on Twitter: @roxanatabakman.

This article was translated from the Medscape Portuguese edition.

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