Alcohol Misuse: Impact, Screening, and

Brief Interventions

Vince Fonseca, MD, MPH, FACPM2011 State Agency Wellness Conference

Overview

• Background and prevalence• Impact• Screening and Brief Interventions

Background and Prevalence

Actual Causes of Death

Alcohol Misuse• A substance use disorder refers to misuse of,

dependence on or abuse of alcohol or other drugs.

• About 19.2 million U.S. workers (15%) reported using or being impaired by alcohol at work at least once in the past year.3

• Alcohol is by far the most widely used drug in the United States: 11% of workers have a problem with alcohol.3

3.“Prevalence and distribution of alcohol use and impairment in the workplace: A U.S. national survey,” J Stud. Alcohol, 67, 1: 147-156, January 2006.

National Objectives• Healthy Workforce 2010: Reduce the cost of lost productivity

in the workplace due to alcohol and drug use. (Developmental)

• Healthy People 2020:– SA14.3 Reduce the proportion of persons engaging in binge drinking

during the past month—Adults aged 18 years and older (27% NSDUH down to 24.3%)

– SA15 Reduce the proportion of adults who drank excessively in the previous 30 days (28.1 to 25.3%)

– SA17 Decrease the rate of alcohol-impaired driving fatalities (.08+ blood alcohol content [BAC]) (.4 to .38 per 100M miles driven)

Texas Adults, Binge-drinking, 2010 BRFSS

Age Group Drinker % 95% CI Binge (% of adults) Binge (% drinkers)

18-2443.9 (36.3-51.4) 21.4 (15.1-27.8)

48.7%

25-3453.9 (49.6-58.2) 21.3 (17.7-24.9)

39.5%

35-4454.5 (51.1-57.9) 16.7 (14.0-19.5)

30.6%

45-5452.6 (49.5-55.7) 14.8 (12.6-16.9)

28.1%

55-6449.4 (46.8-52.1) 9.7 (8.1-11.3)

19.6%

65+37 (35.0-39.1) 3.3 (2.7-4.0)

8.9%

SexMale 58.7 (56.3-61.2) 21.2 (19.1-23.4) 36.1%

Female 41.4 (39.6-43.2) 8.3 (7.2-9.4) 20.0%

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HP 2010 goal 13.4%

Adult binge drinking, Texas, 2007

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Impact

Alcohol Misuse Impact

• Third leading cause of preventable death in the U.S.

• Contributes to injuries resulting from motor vehicle

crashes, fires, falls, and drowning.

• Contributes to violence such as child abuse, homicide,

suicide and personal assault.

• Many chronic conditions are also attributable to

alcohol use, including gastrointestinal diseases, certain

cancers, mental disorders, and certain cardiovascular

diseases.

Alcohol Misuse Impact-Texas Deaths

Overall Males Females

Chronic Causes 2508 1829 680

Acute Causes 3371 2513 859Total for All Causes 5880 4341 1538

Chronic Causes 2,508

Liver 60%

CVD 15%

Alcohol Use Disorder 12%Acute Causes 3,371

Violence 35%

Unintentional 65%

CDC’s ARDI software estimateshttp://apps.nccd.cdc.gov/DACH_ARDI/Default/Default.aspx

Worksite Impact• Increased healthcare and insurance costs– Healthcare costs for employees with alcohol

problems are twice those for other employees.9 – People who abuse drugs or alcohol are 3.5x more

likely to be involved in a workplace accident than other workers.10

• More turnover – People with drug or alcohol problems were more

likely than others to report having worked for three or more employers in the previous year.13

9 Schneider Institute for Health Policy, Brandeis University, Substance Abuse, The Nation's Number One Health Problem, Princeton, NJ: Robert Wood Johnson Foundation, February 2001: 70.

10 US DHHS, SAMHSA, 1999 National Household Survey on Drug Abuse,Rockville, MD: US DHHS, 2000

13“Worker SubstanceUse and Workplace Policies and Programs,” DHHS Pub No. SMA 07-4273, Rockville, MD: SAMHSA, OAS, 2007.

Worksite Impact• Reduced productivity – More likely to exhibit job withdrawal behaviors,

such as spending work time on non-work-related activities, taking long lunch breaks, leaving early, or sleeping on the job.11

– More likely to experience hangovers that cause them to be absent from work; show up late or leave early; feel sick at work; perform poorly; or argue with their coworkers.11

11“The Cost to Employers of Employee Alcohol Abuse: A Review of the Literature in the USA,” Bulletin on Narcotics, Vol. LII, Nos. 1 & 2, Geneva: United Nations Office on Drugs and Crime, 2000.

Alcohol-related Excess CostsNumber of Workers 250,000

Number with alcohol problem 17,084

Excess workdays lost 683 Cost of excess lost days per year: $1,235,301

Alcohol-related health care costs $37,587,500

Excess Emergency Room Visits at $1,191.81/visit

3,605 excess visits

$4,296,475

Excess Days in the Hospital at $5,306.68/day 929 excess days

$4,929,906

Emergency Department and Hospital Costs $9,226,381

http://www.cdc.gov/nccdphp/dnpao/hwi/programdesign/costcalculators.htm

Screening and Intervention

Prevention in the Workplace• Primary Prevention: activities directed at

employed populations that are generally healthy– Below harmful alcohol consumption levels– No relationship, work, or injury problems

• Secondary Prevention: directed at individuals already at higher risk because of certain lifestyle practices (screening and risk reduction)– Consuming harmful amounts of alcohol– Relationship, work, or injury problems

• Tertiary Prevention: disease management– Treatment, referrals, and self-management

Assessment of Health Risk with Feedback and Health Education

Screening and Services Saves $

• When workers with substance use disorders get treatment both employers and employees benefit through: – Better employee health and lower total healthcare

costs over time – Less absenteeism – Improved job performance– Reduced costs associated with short- and long-term

disability and workers’ compensation – Fewer accidents and less corporate liability.14

14 SAMHSA, CSAT, “Substance Abuse in Brief: Effective Treatment SavesMoney,” Rockville, MD: SAMHSA CSAT, January 1999.

Stigma and Shame

• Substance abuse stigma and shame often increases the severity of the problem.

• Individuals may be reluctant to acknowledge that they suffer from alcohol or drug problems

• Individuals may be reluctant unwilling to seek treatment, even if it is available.

Screening and Brief Intervention (SBI)

• SBI identifies and helps people with alcohol problems.

• Through this technique, healthcare professionals use a short interview to learn whether a person has an alcohol problem. When a problem is discovered, a brief intervention of 1-5 short sessions can treat most people. People with more severe problems can be referred to more intensive treatment programs.

Elements of Brief Interventions

• Present screening (e.g. AUDIT) results

• Identify risks and discuss consequences

• Provide medical advice

• Solicit patient commitment

• Identify goal—reduced drinking or abstinence

• Give advice and encouragement

Screening and Brief Intervention (SBI) ROI

% Identified Savings

Cost Net Savings

80% $8,795,335 $2,788,109 $6,007,226

60% $6,596,501 $2,091,082 $4,505,419

40% $4,397,668 $1,742,568 $2,655,100

20% $2,198,834 $697,027 $1,501,807

Baseline: 8% identified …92% receive no services

http://www.cdc.gov/nccdphp/dnpao/hwi/programdesign/costcalculators.htm

Direct Medical CostsNational Commission on Prevention Priorities

Health Affairs, 29, no. 9 (2010): 1656-1660• Cost Saving per year

– Discuss daily aspirin use– Smoking cessation advice and help to quit– Alcohol screening and brief counseling– Obesity screening– Pneumococcal immunization (>65 years)– Vision screening (>65 years)

• <$10 per person per year– Tetanus booster– Chlamydia screening– Discuss folic acid use– Influenza immunization—adults 50+

• $15-$50 per person per year– Colorectal cancer screening– Hypertension screening and treatment– Cervical cancer screening– Depression screening – Hearing screening (>65 years)

• $61-$104 per person per year– Osteoporosis screening—women 60+– Breast cancer screening—women 40+ – Cholesterol screening and treatment—men 35+, women 45+

Target High Value Services• Insurance coverage doesn’t mean that high value

services will be delivered• Environmental, policy and system changes• Target high-value services to specific individuals– Use comprehensive HRA (anonymously)

• Behavior change support (tobacco, alcohol, physical activity, healthy eating, breastfeeding)

• Aspirin to prevent heart attack and cardiometabolic control• Cancer screening• Immunization need

– Tailor the message and program• Evaluate outcomes– Reports for ongoing and retrospective results

Workplace Strategies

• Provide employees access to counseling and referrals to treat substance abuse.

• Participate in community efforts to prevent substance abuse.

• Offer an anonymous HRA to all employees, and encourage follow-up services for those at risk.

• Establish or link EAP to health promotion initiatives.

• Establish worksite alcohol and drug policies.