Alcohol Misuse Screening & Behavioral Counseling

Fact Sheet and Resources

Alcohol misuse is the third leading cause of preventable deaths in the United States.

Alcohol misuse during pregnancy can lead to the development of fetal abnormalities known as fetal alcohol spectrum disorders (FASDs).

Screening for alcohol misuse among pregnant women and referral for treatment has been found to be an effective prevention strategy for fetal alcohol spectrum disorders (FASDs).

U.S. Preventive Services Task Force (USPSTF) Grade: B
USPSTF Recommendation:
Screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. No recommendation for adolescents.1

Alcohol misuse - Provider Fact Sheet PDF file PDF - 102.54 KB

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Why is this important?

Alcohol misuse is the third leading cause of preventable deaths in the United States causing more than 88,000 deaths per year.2

Alcohol is used by approximately 15% of pregnant women, with rates as high as 20% reported in recent decades.3

Studies identified at least two distinct groups at risk for alcohol misuse during pregnancy:

  1. age >35 years, have a high socioeconomic status and level of education, not users of any illicit drugs, married, non-Hispanic white, with a 6% to 15% probability of using alcohol during pregnancy and
  2. age < 30 years, single, smoke cigarettes, poly-substance user (marijuana being the most common comorbid drug), more likely to binge drink during pregnancy, with 1% to 3% prevalence of alcohol use during pregnancy.3

The Centers for Disease Control and Prevention (CDC) states that there is no known safe amount of alcohol use during pregnancy or while trying to get pregnant. There is also no safe time during pregnancy to drink. All types of alcohol are equally harmful, including all wines and beer. Drinking alcohol during pregnancy can cause miscarriage, stillbirth, and a range of lifelong physical, behavioral, and intellectual disabilities. These disabilities are known as fetal alcohol spectrum disorders (FASDs).4

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How frequently is this preventive service being provided?

The CDC reports that 1 in 6 (roughly 17%) adults (includes pregnant women subgroup) are asked by their doctor or health provider about drinking.5

In a study of over 12,000 women who drank alcohol during their third trimester, 30% reported that their health care provider did not counsel them on the effects of alcohol use on their child.6

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What are the best screening practices identified in the literature?

The USPSTF considers three tools as the instruments of choice for screening for alcohol misuse in the primary care setting: the Alcohol Use Disorders Identification Test (AUDIT), the abbreviated AUDIT-Consumption (AUDIT-C), and single–question. Brief multi–contact (each contact is 6–15 minutes) behavioral counseling seems to have the best evidence of effectiveness.1

Three recommended screening tools specifically for pregnant women are T-ACE, TWEAK, and 4-Ps [PDF]. T-ACE was proven effective in randomized trials.7

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What are the best interventions identified in the literature?

A meta-analysis on behavioral counseling interventions in primary care to reduce risky alcohol use by adults identifies brief multi-contact behavioral interventions (initial session up to 15 min with follow-ups) as most successful in increasing cessation odds and improving health outcomes. Very brief (one session up to five min) or brief interventions (one session up to 15 min) had no impact among the general cohort8; however, brief interventions among the pregnant population exhibited positive results (reduction in alcohol use), as they are generally more motivated to avoid pregnancy risk factors.9

Effective interventions included: advice, feedback, goal setting, and additional contacts for assistance and support. They generally followed the 5-As (assess, advise, agree, assist, arrange). Studies that identified significant positive results varied in who delivered the intervention (e.g. physician, health educators, counselors, clinic nurses).10 Partner participation during the intervention also improved the results.11

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What barriers exist for providers?

  • Perceived lack of physician time
  • Lack of familiarity with screening tools
  • Lack of training in managing positive results
  • Lack of available treatment resources

Support systems are probably required for effective screening and intervention and most interventions require trained providers or staff.12

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What are some ideas to address these barriers?

  • Make more tools and resources available for patients to increase the likelihood of uptake of these preventive services.
  • More provider education needs to be performed so that a consistent message is given to prenatal patients to abstain from alcohol during every state of pregnancy.13

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What does the Affordable Care Act cover?

All Marketplace plans and many other plans must cover alcohol misuse screening and counseling for adults without charging a copayment or coinsurance. This is true even if the patient has not met their yearly deductible. This applies only when these services are delivered by a network provider.14

The specific substance abuse services that will be covered are currently being determined by the Department of Health and Human Services (HHS), and will take into account evidence on what services allow individuals to get the treatment they need and help them with recovery.15

The Centers for Medicare and Medicaid Services (CMS) also provides information about preventive service coverage. provides lists of preventive care benefits for all adults and those specific to women.

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What does Medicaid cover?

Each state has its own plan for Medicaid coverage. To find out more about Medicaid and coverage in your state, please visit

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1 U.S. Preventive Services Task Force. (2013). Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Current Recommendations

2 Centers for Disease Control and Prevention. Alcohol and Public Health: Fact Sheets- Alcohol Use and Your Health.

3 Bhuvaneswar, Chaya G., et al. "Alcohol use during pregnancy: prevalence and impact." Primary care companion to the Journal of clinical psychiatry 9.6 (2007): 455.

4 Centers for Disease Control and Prevention. (2014). Fetal Alcohol Spectrum Disorders (FASDs): Alcohol Use in Pregnancy.

5 Centers for Disease Control and Prevention. Alcohol and Public Health: Fact Sheets- Alcohol Use and Your Health.

6 Cheng D, Kettinger L, Uduhiri K, Hurt L. Alcohol consumption during pregnancy: prevalence and provider assessment. Obstet Gynecol. 2011;117(2 Pt 1):212-7.

7 Haug NA, Duffy M, Mccaul ME. Substance Abuse Treatment Services for Pregnant Women: Psychosocial and Behavioral Approaches. Obstet Gynecol Clin North Am. 2014;41(2):267-296.

8 Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. (2004). Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med; 140(7):557-68.

9 U.S. Department of Health and Human Services. (2009). Reducing Alcohol-Exposed Pregnancies. [PDF]

10 Whitlock, E. P., Polen, M. R., Green, C. A., Orleans, T., & Klein, J. (2004). Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the US Preventive Services Task Force. Annals of internal medicine; 140(7), 557-568.

11 Chang G. (2001). Alcohol-screening instruments for pregnant women. Alcohol Res Health; 25(3):204-9.

12 U.S. Preventive Services Task Force. (2012). Behavioral Counseling After Screening for Alcohol Misuse in Primary Care: A Systematic Review and Meta-Analysis for the U.S. Preventive Services Task Force.

13 Cheng D, Kettinger L, Uduhiri K, Hurt L. (2011). Alcohol consumption during pregnancy: prevalence and provider assessment. Obstet Gynecol; 117(2 Pt 1):212-7.

14 Preventive care benefits.

15 White House Office of National Drug Control Policy. Substance Abuse and the Affordable Care Act.

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For more information

Provider Implementation Tools

CDC Planning and Implementing Screening and Brief Intervention (SBI) for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices [PDF] aims to help practices implement alcohol SBI.

Drinking and Reproductive Health: Tool Kit for Clinicians  
This fetal alcohol spectrum disorders prevention tool kit is for women's health care clinicians. It includes screening and brief intervention tools for the clinician and one-page patient education handouts for download.

Substance Abuse During Pregnancy: Guidelines for Screening and Management (Revised Edition 2015) [PDF]
This information provides all health care professionals working with pregnant women enhance their skills and improve care for women and infants.

Alcohol SBI Guide and Website  
These resources from the American College of Obstetricians and Gynecologists can be used in OB/GYN settings.

The Ohio Department of Health Alcohol Screening and Brief Intervention (ASBI) provider tools aim to help educate pregnant women about the dangers of drinking alcohol while pregnant and, in turn, positively influence their decision about reducing or completely ceasing drinking.

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Other Resources

CDC's alcohol SBI initiative includes efforts to support alcohol SBI implementation in medical and other settings, improve tracking of alcohol SBI implementation, and identify and partner with key decision makers, providers, insurers, and employers to develop and implement system-level strategies that foster implementation of alcohol SBI and CHOICES.

Substance Abuse and Mental Health Services Administration's (SAMHSA) Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs.

National Institute on Alcohol Abuse and Alcoholism website focused on women.

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Page last reviewed June 2015
Page originally created April 2015
Internet Citation: Alcohol Misuse Screening & Behavioral Counseling. Content last reviewed June 2015. Agency for Healthcare Research and Quality, Rockville, MD.
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