Professional Documents
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Intoxicación Por Alcohol
Intoxicación Por Alcohol
Description: Update of the 2004 U.S. Preventive Services Task Recommendation: The USPSTF recommends that clinicians screen
Force (USPSTF) recommendation statement on screening and be- adults aged 18 years or older for alcohol misuse and provide
havioral counseling interventions in primary care to reduce alcohol persons engaged in risky or hazardous drinking with brief behav-
misuse. ioral counseling interventions to reduce alcohol misuse. (Grade B
recommendation)
Methods: The USPSTF reviewed new evidence on the effectiveness
The USPSTF concludes that the current evidence is insufficient to
of screening for alcohol misuse for improving health outcomes, the
accuracy of various screening approaches, the effectiveness of var- assess the balance of benefits and harms of screening and behav-
ious behavioral counseling interventions for improving intermediate ioral counseling interventions in primary care settings to reduce
or long-term health outcomes, the harms of screening and behav- alcohol misuse in adolescents. (I statement)
ioral counseling interventions, and influences from the health care
system that promote or detract from effective screening and coun-
seling interventions for alcohol misuse.
Ann Intern Med. 2013;159:210-218. www.annals.org
Population: These recommendations apply to adolescents aged 12 For author affiliation, see end of text.
to 17 years and adults aged 18 years or older. These recommen- * For a list of USPSTF members, see the Appendix (available at www.annals
dations do not apply to persons who are actively seeking evaluation .org).
or treatment of alcohol misuse. This article was published at www.annals.org on 14 May 2013.
Figure. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: clinical summary of U.S.
Preventive Services Task Force recommendation statement.
Recommendation Screen for alcohol misuse and provide brief behavioral No recommendation.
counseling interventions to persons engaged in risky Grade: I statement
or hazardous drinking.
Grade: B
Numerous screening instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity. The USPSTF
prefers the following tools for alcohol misuse screening in the primary care setting:
Screening Tests 1. AUDIT
2. Abbreviated AUDIT-C
3. Single-question screening, such as asking, “How many times in the past year have you had 5 (for men) or 4 (for women
and all adults older than 65 y) or more drinks in a day?”
Counseling interventions in the primary care setting can improve unhealthy alcohol consumption behaviors in adults
Behavioral Counseling engaging in risky or hazardous drinking. Behavioral counseling interventions for alcohol misuse vary in their specific
Interventions components, administration, length, and number of interactions. Brief multicontact behavioral counseling seems to have
the best evidence of effectiveness; very brief behavioral counseling has limited effect.
There is a moderate net benefit to alcohol misuse screening The evidence on alcohol misuse screening and brief
and brief behavioral counseling interventions in the primary behavioral counseling interventions in the primary care
Balance of Benefits and Harms
care setting for adults aged 18 y or older. setting for adolescents is insufficient, and the balance of
benefits and harms cannot be determined.
Other Relevant USPSTF The USPSTF has made recommendations on screening for illicit drug use and counseling and interventions to prevent
Recommendations tobacco use. These recommendations are available at www.uspreventiveservicestaskforce.org.
For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please
go to www.uspreventiveservicestaskforce.org.
means drinking more than the recommended daily, machinery); or have alcohol-related legal or social problems
weekly, or per-occasion amounts resulting in increased risk (4). “Alcohol dependence” (or alcoholism) (defined by the
for health consequences. For example, the National Insti- Diagnostic and Statistical Manual of Mental Disorders,
tute on Alcohol Abuse and Alcoholism (NIAAA) and the Fourth Edition) includes physical cravings and withdrawal
U.S. Department of Agriculture define “risky use” as con- symptoms, frequent consumption of alcohol in larger
suming more than 4 drinks on any day or 14 drinks per amounts than intended over longer periods, and a need for
week for men, or more than 3 drinks on any day or 7 markedly increased amounts of alcohol to achieve intoxi-
drinks per week for women (as well as any level of con- cation (4).
sumption under certain circumstances) (1, 2). “Harmful An estimated 30% of the U.S. population is affected
alcohol use” (defined by the International Statistical Clas- by alcohol misuse, and most of these persons engage in
sification of Diseases and Related Health Problems, Tenth risky use. More than 85 000 deaths per year are attribut-
Revision) is a pattern of drinking that causes damage to able to alcohol misuse; it is the estimated third leading
physical or mental health (3). cause of preventable deaths in the United States (5, 6).
“Alcohol abuse” (defined by the Diagnostic and Statis-
tical Manual of Mental Disorders, Fourth Edition) is drink- Detection
ing that leads an individual to recurrently fail in major The USPSTF found adequate evidence that numerous
home, work, or school responsibilities; use alcohol in phys- screening instruments can detect alcohol misuse in adults
ically hazardous situations (such as while operating heavy with acceptable sensitivity and specificity.
www.annals.org 6 August 2013 Annals of Internal Medicine Volume 159 • Number 3 211
Benefits of Detection and Behavioral Counseling have you had 5 [for men] or 4 [for women and all adults
Interventions older than 65 years] or more drinks in a day?”).
The USPSTF found adequate evidence that brief be- Of available screening tools, AUDIT is the most
havioral counseling interventions are effective in reducing widely studied for detecting alcohol misuse in primary care
heavy drinking episodes in adults engaging in risky or haz- settings; both AUDIT and the abbreviated AUDIT-C have
ardous drinking. These interventions also reduce weekly good sensitivity and specificity for detecting the full spec-
alcohol consumption rates and increase adherence to rec- trum of alcohol misuse across multiple populations. The
ommended drinking limits. Direct evidence about the ef- AUDIT comprises 10 questions and requires approxi-
fectiveness of brief behavioral counseling interventions in mately 2 to 5 minutes to administer; AUDIT-C comprises
pregnant women engaging in alcohol use is more limited. 3 questions and takes 1 to 2 minutes to complete. Single-
However, studies in the general adult population show that question screening also has adequate sensitivity and speci-
such interventions reduce alcohol consumption and in- ficity across the alcohol-misuse spectrum and requires less
crease adherence to recommended drinking limits among than 1 minute to administer.
women of childbearing age.
The USPSTF found insufficient evidence on the effect Behavioral Counseling Interventions
of screening for alcohol misuse and brief behavioral coun- Behavioral counseling interventions for alcohol misuse
seling interventions on outcomes in adolescents. vary in their specific components, administration, length,
Harms of Detection and Behavioral Counseling and number of interactions. They may include cognitive
Interventions behavioral strategies, such as action plans, drinking diaries,
There are minimal data to assess the magnitude of stress management, or problem solving. Interventions may
harms of screening for alcohol misuse or of consequent be delivered by face-to-face sessions, written self-help ma-
brief behavioral counseling interventions in any popula- terials, computer- or Web-based programs, or telephone
tion. However, no studies have identified direct evidence of counseling. For the purposes of this recommendation state-
harms. Thus, given the noninvasive nature of the screening ment, the USPSTF uses the following definitions of inter-
process and behavioral counseling interventions, the related vention intensity: very brief single contact (ⱕ5 minutes),
harms are probably small to none. brief single contact (6 to 15 minutes), brief multicontact
(each contact is 6 to 15 minutes), and extended multicon-
USPSTF Assessment tact (ⱖ1 contact, each ⬎15 minutes). Brief multicontact
The USPSTF concludes with moderate certainty that behavioral counseling seems to have the best evidence of
there is a moderate net benefit to screening for alcohol effectiveness; very brief behavioral counseling has limited
misuse and brief behavioral counseling interventions in the effect (5, 6).
primary care setting for adults aged 18 years or older. The USPSTF found that counseling interventions in
The evidence on screening for alcohol misuse and brief the primary care setting can positively affect unhealthy
behavioral counseling interventions in the primary care set- drinking behaviors in adults engaging in risky or hazardous
ting for adolescents is insufficient, and the balance of ben- drinking. Positive outcomes include reducing weekly alco-
efits and harms cannot be determined. hol consumption and long-term adherence to recom-
mended drinking limits. Because brief behavioral counsel-
ing interventions decrease the proportion of persons who
CLINICAL CONSIDERATIONS engage in episodes of heavy drinking (which results in high
Patient Population Under Consideration blood alcohol concentration [BAC]), indirect evidence
The B recommendation applies to adults aged 18 years supports the effect of screening and brief behavioral coun-
or older, and the I statement applies to adolescents aged 12 seling interventions on important health outcomes, such as
to 17 years. Although pregnant women are included, this the probability of traumatic injury or death, especially that
recommendation is related to decreasing risky or hazardous related to motor vehicles.
drinking, not to complete abstinence, which is recom-
Although screening detects persons along the entire
mended for all pregnant women. These recommendations
spectrum of alcohol misuse, trials of behavioral counseling
do not apply to persons who are actively seeking evaluation
interventions in primary care settings largely focused on
or treatment for alcohol misuse.
risky or hazardous drinking rather than alcohol abuse or
Screening Tests dependence. Limited evidence suggests that brief behav-
The USPSTF considers 3 tools as the instruments of ioral counseling interventions are generally ineffective as
choice for screening for alcohol misuse in the primary care singular treatments for alcohol abuse or dependence. The
setting: the Alcohol Use Disorders Identification Test USPSTF did not formally evaluate other interventions
(AUDIT), the abbreviated AUDIT-Consumption (AUDIT- (such as pharmacotherapy or outpatient treatment pro-
C), and single-question screening (for example, the NIAAA grams) for alcohol abuse or dependence, but the benefits of
recommends asking, “How many times in the past year specialty treatment are well-established and recommended
212 6 August 2013 Annals of Internal Medicine Volume 159 • Number 3 www.annals.org
for persons meeting the diagnostic criteria for alcohol Mental Health Services Administration–Health Resources
dependence. and Services Administration Center for Integrated Health
Screening Intervals Solutions (www.integration.samhsa.gov/clinical-practice
Evidence is lacking to determine the optimal interval /screening-tools). Further details about the single-question
for screening for alcohol misuse in adults. screening method, as well as resources on primary care–
feasible behavioral interventions, are available from the
Suggestions for Practice Regarding the I Statement NIAAA (http://pubs.niaaa.nih.gov/publications/Practitioner
In deciding whether to screen adolescents for alcohol /CliniciansGuide2005/guide.pdf).
misuse and provide behavioral counseling interventions, The Community Preventive Services Task Force rec-
primary care providers should consider the following ommends electronic screening and brief intervention to
factors. reduce excessive alcohol consumption. Electronic screening
and brief intervention uses electronic devices (for example,
Potential Preventable Burden computers, telephones, or mobile devices) to facilitate
In 2010, approximately 14% of adolescents in the 8th screening persons for excessive drinking and delivering a
grade and 41% in the 12th grade reported using alcohol at brief intervention, which provides personalized feedback
least once within the past 30 days; 7% and 23%, respec- about the risks and consequences of excessive drinking.
tively, reported consuming at least 5 or more drinks on a Delivery of personalized feedback can range from being
single occasion (an episode of heavy use) within the previ- fully automated (computer-based) to interactive (provided
ous 2 weeks (7). Motor vehicle crashes are the leading by a person over the telephone). At least 1 part of the brief
cause of death for adolescents (8); according to the Sub- intervention must be delivered by an electronic device.
stance Abuse and Mental Health Services Administration, Electronic screening and brief intervention can be deliv-
about 4% of 16-year-olds and 9% of 17-year-olds in 2009 ered in various settings, such as health care systems, uni-
drove under the influence of alcohol at least once during versities, or communities. The Community Preventive Ser-
the previous year (9). Thirty-seven percent of traffic deaths
vices Task Force found limited information on the
among youth aged 16 to 20 years involve alcohol, and
effectiveness of electronic screening and brief intervention
these deaths frequently involve alcohol-impaired drivers
among adolescents.
with lower BACs than other age groups (10).
The Community Preventive Services Task Force has
also evaluated public health interventions (those that occur
Costs outside of the clinical practice setting) to prevent excessive
Behavioral counseling interventions are associated with alcohol consumption. It recommends instituting liability
a time commitment ranging from 5 minutes to 2 hours, laws for establishments that sell or serve alcohol, increasing
spread over multiple contacts. There are potential financial taxes on alcohol, maintaining limits on days and hours of
costs for parents and caregivers from lost work hours and the sale of alcohol, and regulating alcohol outlet density in
travel to and from the provider. communities as effective in preventing or reducing alcohol-
related harms. It also recommends enhanced enforcement
Potential Harms of laws prohibiting the sale of alcohol to minors. More
Potential harms associated with screening for alcohol information about the Community Preventive Services
misuse include anxiety, stigma or labeling, and interference Task Force’s recommendations on alcohol misuse is avail-
with the clinician–patient relationship. Although evidence able at www.thecommunityguide.org/alcohol/index.html.
is very limited, no direct harms were identified for any The Cochrane Collaboration has performed 2 system-
population in available studies. atic reviews to evaluate the effects of universal school- and
family-based prevention programs to prevent or reduce al-
Current Practice cohol misuse in young people. Although not entirely
Research suggests that although most pediatricians and consistent across studies, evidence generally supported the
family practice clinicians report providing some alcohol effectiveness of certain school-based psychosocial and de-
prevention services to adolescent patients, they do not uni- velopmental programs, such as the Life Skills Training Pro-
versally or consistently screen and counsel for alcohol mis- gram, the Unplugged Program, and the Good Behavior
use (11). Barriers to screening and counseling include a Game (13). Similarly, evidence generally supported small
perceived lack of time, familiarity with screening tools, but positive effects from family-based interventions in pre-
training in managing positive results, and available treat- venting alcohol misuse in young people (14).
ment resources (12). The USPSTF has made recommendations on screen-
Useful Resources ing for and interventions to decrease the unhealthy use of
The AUDIT and AUDIT-C screening instruments for other substances, including illicit drugs and tobacco. More
alcohol misuse are available from the Substance Abuse and information is at www.uspreventiveservicetaskforce.org.
www.annals.org 6 August 2013 Annals of Internal Medicine Volume 159 • Number 3 213
ing on alcohol-related morbidity or mortality in any decreased from an average of about 16 drinks to about 14
population. However, the USPSTF did find adequate evi- drinks per week at 12-month follow-up (24, 25).
dence that brief counseling interventions in adults with On the basis of a meta-analysis of 9 relevant trials, the
screening-detected risky or hazardous drinking positively absolute proportion of adults with screening-detected risky
affect several unhealthy drinking behaviors, including or hazardous drinking who reported not exceeding recom-
heavy episodic (binge) drinking, high average weekly in- mended drinking limits over 12 months increased by 11%
take of alcohol, and consumption above recommended in- (CI, 8% to 13%) in participants receiving behavioral coun-
take limits. seling interventions compared with the control group (5,
Twenty-three randomized, controlled trials (11 of 6). The definition and rationale of a given recommended
which were performed in the United States) compared the limit of alcohol consumption may vary to some degree
effects of behavioral counseling interventions with usual across guidelines, making this outcome slightly more sub-
care in adults with screening-detected alcohol misuse. Most jective than the others evaluated by the USPSTF.
interventions evaluated were either brief or brief multicon- A commonly cited standard developed by the NIAAA
tact behavioral counseling interventions that were directly recommends that healthy adult men aged 65 years or
provided by primary care physicians. The mean age of par- younger have no more than 4 drinks per day and no more
ticipants was generally between 30 and 50 years (5, 6). than 14 drinks per week and healthy adult women and all
Studies show that behavioral counseling interventions adults older than 65 years have no more than 3 drinks per
reduce binge drinking. “Binge drinking” is heavy per- day and no more than 7 drinks per week. The NIAAA also
occasion alcohol use; the NIAAA defines it as a pattern of recommends lower levels of consumption or abstinence for
drinking that results in a BAC of 0.08% or higher, gener- adults who receive medications that interact with alcohol,
ally when men consume 5 or more drinks and women have a health condition exacerbated by alcohol, or are preg-
consume 4 or more drinks on 1 occasion within about 2 nant (26). For older adults (aged 65 years or older), 2
hours (20). Meta-analysis from 7 trials showed that behav- studies showed an absolute increase of 9% (CI, 2% to
ioral counseling interventions resulted in a 12% absolute 16%) in the proportion of risky or hazardous drinkers who
increase in the proportion of adult participants with adhered to recommended drinking limits after behavioral
screening-detected risky or hazardous drinking who re- counseling at 1-year follow-up (24, 25). There was not
ported no heavy drinking episodes after 1 year compared enough evidence to assess whether there are relative differ-
with the control group (95% CI, 7% to 16%). Subgroup ences in the effect for younger adults.
analyses suggest that single-contact interventions may be A single study meeting inclusion criteria was identified
less effective or ineffective compared with multicontact ap- for pregnant women. In this trial, 250 pregnant women
proaches (5, 6). with a gestational age of 28 weeks or less were randomly
In younger adults (such as college age), 3 trials pro- assigned to comprehensive assessment only or assessment
vided evidence that behavioral counseling interventions re- and a 45-minute behavioral counseling intervention. The
duced the frequency of heavy drinking episodes by about 1 study found a sustained reduction in the daily consump-
day per month (average baseline, 6 to 7 heavy drinking tion of alcohol in both groups (with no significant differ-
days per month) at 6 months of follow-up (21–23). The ence between them); it also found that women who ab-
evidence was insufficient to evaluate whether there are rel- stained from alcohol at baseline in the behavioral
ative differences in the effect for older adults (aged 65 years intervention group were more likely to do so than women
or older). in the control group (86% vs. 72%; P ⫽ 0.04) (27). Only
Behavioral counseling interventions also reduce the to- 1 study meeting inclusion criteria included women who
tal number of drinks per week consumed by adults with were breastfeeding (28), and they made up less than 30%
screening-detected risky or hazardous drinking. A standard of the total population. However, as previously described,
drink is defined as 12.0 oz of beer, 5.0 oz of wine, or 1.5 oz multiple studies in the general adult population showed
of liquor. Meta-analysis of 10 trials reporting on this out- that behavioral counseling interventions reduce alcohol
come showed that adults receiving behavioral counseling consumption and increase adherence to recommended
interventions reduced their average weekly consumption of drinking limits among women of childbearing age.
alcohol from a baseline of 23 drinks to approximately 19 No studies meeting inclusion criteria were identified
drinks per week at 12-month follow-up compared with the for the effects of brief behavioral counseling interventions
control group (absolute difference, 3.6 fewer drinks per on screening-detected alcohol misuse in adolescents.
week [CI, 2.4 to 4.8]) (5, 6). Among younger adults, data Few studies of behavioral counseling interventions for
from 3 trials conducted in the United States showed that alcohol misuse have rigorously examined longer-term
average consumption decreased from a baseline of about 15 health outcomes, such as alcohol-related morbidity or mor-
drinks to 13 drinks per week at 6-month follow-up (21– tality. Meta-analysis of 6 studies did not find a significant
23). Two studies provided information about the effect of effect of behavioral counseling interventions on all-cause
behavioral counseling on weekly alcohol consumption rates mortality (rate ratio, 0.52 [CI, 0.22 to 1.2]), although
in older adults; pooled analysis showed that consumption findings generally trended favorably for the intervention
www.annals.org 6 August 2013 Annals of Internal Medicine Volume 159 • Number 3 215
groups. However, because none of the studies was designed illicit substance use, if persons receiving screening or be-
or powered to detect a difference in mortality, it is difficult havioral counseling interventions for risky drinking replace
to draw any firm conclusions about the true effect (5, 6). A 1 harmful substance with another.
sizable body of observational evidence does show a link No studies directly evaluated the harms of screening;
between increasing alcohol consumption levels and risk for few studies reported information about harms resulting
traumatic injury or death. from behavioral counseling interventions. Two studies
A 2010 systematic review and meta-analysis of case– found no changes in anxiety levels among adults with
control and case-crossover studies evaluating the associa- screening-detected alcohol misuse receiving behavioral
tion between level of acute alcohol consumption and prob- counseling, and 5 studies qualitatively described that ciga-
ability of an injury related to a motor vehicle crash found a rette consumption seemed unchanged among adults receiv-
rapidly increasing dose–response relationship between the ing counseling interventions (5, 6). No specific informa-
2 variables. For the consumption of 24 g of alcohol (or tion was available for the adolescent population. No direct
about 2 standard drinks) within a 6-hour period, the odds evidence of harm from screening or behavioral counseling
ratio of being injured in a motor vehicle crash is 2.20 for alcohol misuse was identified in any study; given the
compared with no alcohol intake; at 4 to 5 drinks con- noninvasive nature of these practices, the adverse effects are
sumed (a rough proxy for the NIAAA definition of a heavy likely to be small to none.
drinking episode), the odds ratio is about 5.00 to 10.00,
and after 10 drinks, the odds ratio is 52.00 (29). A review Estimate of Magnitude of Net Benefit
of case– control roadside surveys evaluating the relationship Adequate evidence supports a moderate beneficial ef-
between BAC in drivers involved in motor vehicle crashes fect of screening for alcohol misuse followed by brief be-
compared with those not involved in incidents found that havioral counseling interventions in adults engaged in risky
the relative probability of a motor vehicle crash resulting in or hazardous drinking. Unhealthy drinking behaviors in
injury or death increased sharply after attainment of a BAC this population, including heavy episodic drinking, high
of about 0.08% (relative risk ranged from about 2 to 4 at a daily or weekly levels of alcohol consumption, and exceed-
BAC of 0.08% compared with a BAC of 0.00%, with ing recommended drinking limits, can all be reduced
sharper increases at higher BACs) (30). through screening and behavioral counseling in the pri-
Screening for alcohol misuse will detect persons engag- mary care setting. Although limited specific evidence for
ing in a spectrum of unhealthy drinking behaviors, not just pregnant women was found, the USPSTF determined that
risky or hazardous drinking. However, most available stud- available studies of behavioral counseling interventions for
ies of behavioral counseling interventions focused on risky alcohol misuse in the general adult population apply to
or hazardous drinking and either specifically excluded per- pregnant adult women.
sons with alcohol dependence or used enrollment criteria Available studies have not focused on the effect of
that necessarily restricted participation by such persons. screening and behavioral counseling on longer-term health
The limited evidence available for persons with alcohol outcomes, such as alcohol-related disease or death. How-
dependence suggests that brief behavioral counseling inter- ever, epidemiologic evidence supports an association be-
ventions may be ineffective in this population (5, 6). The tween increasing alcohol consumption and increased risk
effectiveness of behavioral counseling in primary care set- for morbidity and mortality related to a motor vehicle
tings for persons engaging in harmful alcohol use or alco- crash, providing indirect support that counseling interven-
hol abuse is uncertain. tions—which reduce acute and sustained alcohol intake
Although the USPSTF did not formally assess the ev- levels—can help improve some health outcomes in alcohol
idence on interventions for alcohol dependence, a range of misuse (29, 30). A large body of observational evidence
treatment options with established efficacy exists, including also links alcohol use in pregnant women with an increased
12-step programs (such as Alcoholics Anonymous), inten- risk for subsequent birth defects (31, 32).
sive outpatient or inpatient treatment programs, and phar- Given the noninvasive nature of screening and coun-
macotherapy. However, the relative effectiveness of the seling interventions for alcohol misuse, the USPSTF as-
various treatment approaches has not been systematically sessed the range of probable harms to be small to none.
examined in randomized trials and the USPSTF was un- Therefore, given moderate benefit and little to no associ-
able to identify any trials of pharmacotherapy in the pri- ated harm, the USPSTF concludes with moderate certainty
mary care setting. that the net benefit of screening adults, including younger
adults, for alcohol misuse and providing brief behavioral
Potential Harms of Screening and Behavioral Counseling counseling interventions for those engaged in risky or haz-
Very limited evidence is available on the harms of ardous drinking is moderate.
screening and behavioral counseling for alcohol misuse. No studies were identified that addressed screening
Possible harms include anxiety, labeling, discrimination, or and behavioral counseling interventions for alcohol misuse
interference with the doctor–patient relationship. An addi- in adolescents. As such, the USPSTF concludes that the
tional effect might be a consequent increase in smoking or evidence is insufficient to assess the balance of benefits and
216 6 August 2013 Annals of Internal Medicine Volume 159 • Number 3 www.annals.org
harms of screening and behavioral counseling for alcohol stance abuse screening test, at every health supervision visit
misuse in this population. and appropriate acute care visits and respond to screening
Response to Public Comments
results with the appropriate brief intervention (35).
A draft version of this recommendation statement was From the U.S. Preventive Services Task Force, Rockville, Maryland.
posted on the USPSTF Web site from 24 September 2012
to 22 October 2012. Several comments indicated that the Disclaimer: Recommendations made by the USPSTF are independent of
USPSTF should more clearly emphasize the need for more the U.S. government. They should not be construed as an official posi-
research on screening and counseling interventions for al- tion of the Agency for Healthcare Research and Quality or the U.S.
cohol misuse in the adolescent population; this was added Department of Health and Human Services.
to the Research Needs and Gaps section. Some comments
requested the inclusion of recommended screening instru- Financial Support: The USPSTF is an independent, voluntary body.
ments; links to these tools were added to the Useful Re- The U.S. Congress mandates that the Agency for Healthcare Research
and Quality support the operations of the USPSTF.
sources section. Several comments indicated that there was
insufficient explanation of the distinctions between risky
Potential Conflicts of Interest: None disclosed. Disclosure forms from
drinking and alcohol dependence, as well as what consti-
USPSTF members can be viewed at www.acponline.org/authors/icmje
tutes “binge” drinking or a “drink”; expanded definitions /ConflictOfInterestForms.do?msNum⫽M13-0959.
and examples were added to the Rationale and Discussion
sections. Requests for Single Reprints: Reprints are available from the USPSTF
Web site (www.uspreventiveservicestaskforce.org).
www.annals.org 6 August 2013 Annals of Internal Medicine Volume 159 • Number 3 217
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* The USPSTF defines certainty as “likelihood that the USPSTF assessment of the net benefit of a preventive service is correct.” The net benefit is defined as benefit minus
harm of the preventive service as implemented in a general primary care population. The USPSTF assigns a certainty level on the basis of the nature of the overall evidence
available to assess the net benefit of a preventive service.
W-76 6 August 2013 Annals of Internal Medicine Volume 159 • Number 3 www.annals.org