Screen and Assess: Use Quick, Effective Methods

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    Takeaways

    • Alcohol screening and brief intervention ranks highly among effective preventive services based on its cost-effectiveness and potential to reduce clinically preventable burden.
    • Screening for heavy drinking can be done easily and effectively if you make it a routine part of care and use a brief tool recommended by the U.S. Preventive Services Task Force that identifies people with unhealthy alcohol use.
    • If a patient screens positive for heavy drinking, a quick assessment can guide the next steps by indicating whether the patient has alcohol use disorder (AUD).

    Screening for unhealthy alcohol use, combined with a brief intervention when needed, is a top preventive service in terms of potential health impacts and cost effectiveness.1 Many healthcare professionals may feel uncomfortable asking patients about their drinking, however, and may be concerned that the answers could raise issues that require more time, resources, and knowledge than they can offer.2,3

    Here, we describe quick, effective alcohol screening tools and clear steps to take depending on patient answers. You may increase comfort levels for yourself and your patients by making this process routine and by reassuring patients that “we ask everyone.” We link to other Core articles and resources to help with follow-up and offer a simplified sample workflow at the end of this article.  

    A note on drinking level terms in this Core article: The 2020-2025 U.S. Dietary Guidelines states that for adults who choose to drink alcohol, women should have 1 drink or less in a day and men should have 2 drinks or less in a day. These amounts are not intended as an average but rather a daily limit. Heavy drinking has been defined for women as 4 or more drinks on any day or 8 or more per week, and for men as 5 or more drinks on any day or 15 or more per week.

    Why is it important to ask about alcohol use?

    Here are four good reasons to talk with your patients about their use of alcohol:

    • Alcohol use contributes to common health problems: Heavy alcohol use can increase the odds for injuries and other acute problems as well as chronic illnesses such as liver disease, hypertension, and depression.4–6 Alcohol use can promote disease progress while compromising self-care and treatment outcomes. Even alcohol use within the U.S. Dietary Guidelines is not risk-free, as it can raise cancer risks and interact with medications.7 (See Core articles on medical complications and medication interactions.)
    • Alcohol screening and brief intervention can reduce drinking levels: Research has demonstrated that brief interventions with patients who screen positive for heavy drinking can reduce alcohol use and is cost effective in primary care settings.8–12 Based on estimates of cost-effectiveness and preventable disease burden, alcohol screening and brief intervention ranks higher than other common preventive practices such as screening for hypertension, high cholesterol, and cancer.1
    • Early detection averts greater harm: It’s a myth that people who drink heavily or have AUD need to hit “rock bottom” before changing their drinking patterns. As with any other health condition, it’s better to prevent alcohol problems from developing or to treat them before they become severe.
    • Asking about alcohol may help an entire family: Family members of those with alcohol use disorder (AUD) have more health problems and more costly medical care than family members of those without AUD,13 or even those with other chronic medical problems.14 Thus, identifying individuals with alcohol problems may make a difference in the whole family’s health.

    Who should conduct screening?

    Any healthcare professional in medical or mental health fields can easily screen for heavy drinking15–18 as part of a comprehensive assessment or health history. In primary care, teams that include nurses and other non-physician providers are increasingly used for alcohol screening. Patient self-reporting on paper, a tablet, or online (such as through a patient portal) may provide more accurate answers than asking directly.19,20 Regardless of how screening is administered, entering the results into the patient’s medical chart or electronic health record (EHR) can facilitate collaborative care.

    What quick and effective screening questions should I ask?

    Because of time pressures, it is practical for primary care professionals to use a brief screener that asks about heavy drinking days, then to ask follow-up questions as needed. 

    • Do use:
      • For adults, the U.S. Preventive Services Task Force (USPSTF) recommends using one of the following two brief tools, noting that they have good sensitivity and specificity across the spectrum of unhealthy alcohol use.21 Each tool asks about heavy drinking days and requires only 1-2 minutes to administer.
        • The Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) consists of three questions related to drinking frequency and quantity. Responses can be scored with a paper form or within the EHR. The higher the score, the more likely alcohol is affecting a patient's health and safety.22 (Note: The AUDIT-C questions are a subset of the full 10-question AUDIT [PDF – 172 KB]. A USA­­UDIT [PDF – 1.77 MB] version is adapted for U.S. standard drink sizes and limits.)
        • The NIAAA Single Alcohol Screening Question (SASQ) is “How many times in the past year have you had (4 for women, or 5 for men) or more drinks in a day?” A response of one or more warrants follow-up (see the section “When patients screen positive…,” below). Because it is not a scored instrument, the SASQ can be woven easily into a verbal clinical interview. Before asking the SASQ, you can ask a prescreen along the lines of “How often did you have a drink containing alcohol in the past year?”
      • For adolescents, pregnant women, and culturally diverse populations, see the Resources section, below, for additional screening tools and guidance from NIAAA and professional organizations.
    • Do not use:
      • Avoid “yes/no” or leading questions such as “Did you drink (4 for women, or 5 for men) drinks at one sitting?” or “You don’t drink very often, do you?”
      • Avoid the still widely used but outdated “CAGE” as a screening tool (CAGE is an acronym for four questions: Cut down, Annoyed, Guilty, Eye-opener). The USPSTF does not recommend the CAGE for screening because it does not identify all patients who could benefit from a brief intervention.21,23 The CAGE only captures patients already experiencing adverse consequences of heavy drinking, so you miss many prevention opportunities.23

    Are laboratory tests available to screen for or monitor alcohol problems?

    Laboratory tests are not a substitute for drinking self-report measures, but they can serve as an objective means to help identify whether patients drink heavily or have alcohol-related health problems.24 Discussing the results of initial and follow-up testing with patients may also help motivate them and reinforce their progress in treatment.25 Older and more readily measurable biomarkers such as serum gamma-glutamyl transferase (GGT) and serum carbohydrate-deficient transferrin (CDT) indirectly reflect alcohol consumption, whereas some newer assays directly measure alcohol metabolites such as serum phosphatidyl ethanol (PEth) and urinary ethyl glucuronide (EtG).26,27

    See the Resources section below for a helpful advisory on how these and other biomarkers can help support alcohol screening, motivate patients to change drinking behavior, and identify returns to heavy drinking that often occur in recovery, so that you can encourage patients to get back on track. (See Core article on recovery.) The advisory includes information on each test’s window of assessment and sensitivity and specificity.

    When patients screen negative for heavy drinking days, how can I build on that response to reduce future risks?

    When patients who drink alcohol screen negative for heavy drinking days, reinforce or advise that they stay within U.S. Dietary Guidelines of 1 drink or less in a day for women and 2 drinks or less in a day for men.24 Help patients understand that these guidelines are not intended as an average but instead a limit for any single day,24 and that current research indicates, essentially, “the less, the better.”25,26

    Be alert to pregnancy and other health conditions that may warrant advice to not drink at all. (See Core articles on medical complications and medication interactions.) Patients who currently do not drink alcohol are advised by the Dietary Guidelines not to start for their health or “for any reason.”24

    When patients screen positive for heavy drinking days, what are my next steps?

    Following a positive screen, ask a few questions to get a more complete picture of the patient’s drinking pattern and determine whether the patient has symptoms of AUD.

    • Ask about the typical weekly drinking pattern. The more frequent the heavy drinking days, and the greater the weekly volume, the greater the risk of having AUD.27 To learn the typical weekly pattern, ask, “On average, how many days a week do you drink alcohol?” and “On a typical drinking day, how many drinks do you have?” Multiply the answers to get the typical weekly amount, which will serve as a baseline for follow-up. Keep in mind that heavy weekly drinking is defined as 8 or more drinks for women and 15 or more for men.
    • Conduct a quick AUD assessment to determine the next steps. Assessment instruments can be used efficiently through EHRs or by self-report. Among the possible tools, an 11-item Alcohol Symptom Checklist [PDF – 80 KB] based on the diagnostic criteria for AUD has the advantage of directly providing a diagnosis and level of severity. Below are the criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).28 Mild AUD is 2-3 symptoms, moderate AUD is 4-5 symptoms, and severe AUD is 6 or more symptoms.
      1. Alcohol is often taken in larger amounts or over a longer period than was intended.
      2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
      3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
      4. Craving, or a strong desire or urge to use alcohol.
      5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
      6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
      7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
      8. Recurrent alcohol use in situations in which it is physically hazardous.
      9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
      10. Tolerance, as defined by either of the following:
        1. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
        2. A markedly diminished effect with continued use of the same amount of alcohol.
      11. Withdrawal, as manifested by either of the following:
        1. The characteristic withdrawal syndrome for alcohol (See the “How is alcohol withdrawal managed?” section for some DSM-5 symptoms of withdrawal).
        2. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

    Many patients with AUD may also experience dysphoria and irritability when the effects of alcohol are wearing off. (See Core article on neuroscience.)

    Patient responses to assessment questions offer opportunities to engage them in exploring their own reasons for making a change in their drinking. (See Core article on brief intervention). Routinely integrating an Alcohol Symptom Checklist [PDF – 80 KB] into primary care may make it easier for healthcare professionals to hold comfortable, patient-centered, non-judgmental conversations about alcohol that help destigmatize AUD and its treatment.29,30

    After assessing for AUD, what are my next steps?

    After you assess your patients for AUD, advise and assist them toward cutting back or quitting. Here are the next steps in brief (these are spelled out in more detail in other Core articles):

    • For patients who drink heavily and do not have AUD: Offer brief advice to cut back to the Dietary Guidelines levels or to quit if medically indicated. If a patient is hesitant to accept that drinking goal at first, then negotiate an individualized, initial goal, such as cutting back significantly, ideally to include no heavy drinking days, with an ultimate goal of cutting back to Dietary Guidelines levels or abstaining if indicated. Follow up at the next visit.
    • For patients who have AUD: Advise abstinence and emphasize that it’s important to cut down gradually because suddenly stopping can result in alcohol withdrawal, which can be life threatening (see Core article on AUD). Be cautious and consider the need for medically managed withdrawal. Again, if the patient is hesitant to abstain, then negotiate individualized drinking goals, with, for example, a starting goal of no heavy drinking days and an ultimate goal of abstaining or cutting back to the Dietary Guidelines levels. Discuss evidence-based professional treatment as well as mutual support group options. Consider support in primary care with FDA-approved AUD medications, which are easy to prescribe, and regular follow-ups. Consider referral to specialty care, especially for patients with mental health comorbidities or more severe AUD. Follow up at the next visit.

    For tips on holding these conversations with patients using motivational interviewing, see the Core article on brief intervention. For other practical insights on how to help your patients with AUD, see also the Core articles on treatment, referrals, and recovery.

    In closing, with a few brief questions, you can determine whether your patients are drinking at levels that may have adverse health effects and whether, in addition, they have symptoms of AUD. From there, you’ll be able to set a clear path to help improve your patients’ risk profile, health, and wellbeing. A simplified sample workflow of this process is shown below and can be downloaded here.

    Resources

    Further Reading in the NIAAA Journal, Alcohol Research Current Reviews

    Fetal Alcohol Spectrum Disorders

    Alcohol SBIRT Resources Related to this Article

    Adolescent Primary Care

    Adapting alcohol SBIRT to culturally diverse populations

    Biomarkers

    Resources to Share with Patients Related to this Article

    Reimbursement

    More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care.

    References

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    2. Johnson M, Jackson R, Guillaume L, Meier P, Goyder E. Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. J Public Health Oxf Engl. 2011;33(3):412-421. doi:10.1093/pubmed/fdq095
    3. Williams EC, Achtmeyer CE, Young JP, et al. Local Implementation of Alcohol Screening and Brief Intervention at Five Veterans Health Administration Primary Care Clinics: Perspectives of Clinical and Administrative Staff. J Subst Abuse Treat. 2016;60:27-35. doi:10.1016/j.jsat.2015.07.011
    4. Mertens JR, Lu YW, Parthasarathy S, Moore C, Weisner CM. Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO: comparison with matched controls. Arch Intern Med. 2003;163(20):2511-2517. doi:10.1001/archinte.163.20.2511
    5. Mertens JR, Weisner C, Ray GT, Fireman B, Walsh K. Hazardous drinkers and drug users in HMO primary care: prevalence, medical conditions, and costs. Alcohol Clin Exp Res. 2005;29(6):989-998. doi:10.1097/01.alc.0000167958.68586.3d
    6. Scott KM, Lim C, Al-Hamzawi A, et al. Association of Mental Disorders With Subsequent Chronic Physical Conditions. JAMA Psychiatry. 2016;73(2):150-158. doi:10.1001/jamapsychiatry.2015.2688
    7. U.S. Department of Health & Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. HHS; 2016:413.
    8. Bertholet N, Daeppen JB, Wietlisbach V, Fleming M, Burnand B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med. 2005;165(9):986-995. doi:10.1001/archinte.165.9.986
    9. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addict Abingdon Engl. 1993;88(3):315-335. doi:10.1111/j.1360-0443.1993.tb00820.x
    10. D’Onofrio G, Degutis LC. Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Acad Emerg Med Off J Soc Acad Emerg Med. 2002;9(6):627-638. doi:10.1111/j.1553-2712.2002.tb02304.x
    11. Kaner EFS, Dickinson HO, Beyer F, et al. The effectiveness of brief alcohol interventions in primary care settings: A systematic review. Drug Alcohol Rev. 2009;28(3):301-323. doi:https://doi.org/10.1111/j.1465-3362.2009.00071.x
    12. Kaner EFS, Beyer F, Dickinson HO, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007;(2):CD004148. doi:10.1002/14651858.CD004148.pub3
    13. Ray GT, Mertens JR, Weisner C. The excess medical cost and health problems of family members of persons diagnosed with alcohol or drug problems. Med Care. 2007;45(2):116-122. doi:10.1097/01.mlr.0000241109.55054.04
    14. Ray GT, Mertens JR, Weisner C. Family Members of Persons with Alcohol or Drug Dependence: Health Problems and Medical Cost Compared to Family Members of Persons with Diabetes and Asthma: Family Members of Persons with AODD. Addict Abingdon Engl. 2009;104(2):203-214. doi:10.1111/j.1360-0443.2008.02447.x
    15. Babor TE, Higgins-Biddle J, Dauser D, Higgins P, Burleson JA. Alcohol screening and brief intervention in primary care settings: implementation models and predictors. J Stud Alcohol. 2005;66(3):361-368. doi:10.15288/jsa.2005.66.361
    16. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99(1-3):280-295. doi:10.1016/j.drugalcdep.2008.08.003
    17. Mertens JR, Chi FW, Weisner CM, et al. Physician versus non-physician delivery of alcohol screening, brief intervention and referral to treatment in adult primary care: the ADVISe cluster randomized controlled implementation trial. Addict Sci Clin Pract. 2015;10. doi:10.1186/s13722-015-0047-0
    18. Sterling S, Kline-Simon AH, Satre DD, et al. Implementation of Screening, Brief Intervention, and Referral to Treatment for Adolescents in Pediatric Primary Care: A Cluster Randomized Trial. JAMA Pediatr. 2015;169(11):e153145. doi:10.1001/jamapediatrics.2015.3145
    19. Bradley KA, Lapham GT, Hawkins EJ, et al. Quality concerns with routine alcohol screening in VA clinical settings. J Gen Intern Med. 2011;26(3):299-306. doi:10.1007/s11606-010-1509-4
    20. McNeely J, Adam A, Rotrosen J, et al. Comparison of Methods for Alcohol and Drug Screening in Primary Care Clinics. JAMA Netw Open. 2021;4(5):e2110721-e2110721. doi:10.1001/jamanetworkopen.2021.10721
    21. US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(18):1899-1909. doi:10.1001/jama.2018.16789
    22. Alcohol Use Disorders Identification Test (AUDIT-C) - Viral Hepatitis and Liver Disease. Accessed August 9, 2021. https://www.hepatitis.va.gov/alcohol/treatment/audit-c.asp
    23. Tan CH, Hungerford DW, Denny CH, McKnight-Eily LR. Screening for Alcohol Misuse: Practices Among U.S. Primary Care Providers, DocStyles 2016. Am J Prev Med. 2018;54(2):173-180. doi:10.1016/j.amepre.2017.11.008
    24. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th ed.; 2020. DietaryGuidelines.gov
    25. Hartz SM, Oehlert M, Horton AC, et al. Daily Drinking Is Associated with Increased Mortality. Alcohol Clin Exp Res. 2018;42(11):2246-2255. doi:10.1111/acer.13886
    26. Griswold MG, Fullman N, Hawley C, et al. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet. 2018;392(10152):1015-1035. doi:10.1016/S0140-6736(18)31310-2
    27. Dawson DA, Grant BF, Li TK. Quantifying the Risks Associated With Exceeding Recommended Drinking Limits. Alcohol Clin Exp Res. 2005;29(5):902-908. doi:https://doi.org/10.1097/01.ALC.0000164544.45746.A7
    28. American Psychiatric Association. Alcohol-Related Disorders. In: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5. 5th edition. American Psychiatric Publishing; 2013. Reprinted with permission.
    29. Sayre M, Lapham GT, Lee AK, et al. Routine Assessment of Symptoms of Substance Use Disorders in Primary Care: Prevalence and Severity of Reported Symptoms. J Gen Intern Med. 2020;35(4):1111-1119. doi:10.1007/s11606-020-05650-3
    30. Hallgren KA, Matson TE, Oliver M, et al. Practical Assessment of Alcohol Use Disorder in Routine Primary Care: Performance of an Alcohol Symptom Checklist. J Gen Intern Med. Published online August 1, 2021. doi:10.1007/s11606-021-07038-3
    Earn CME/CE Credit

    We invite healthcare professionals including primary care physicians, physician assistants, nurses, pharmacists, and psychologists to complete a post-test after reviewing this article to earn FREE continuing education (CME/CE) credit. This CME/CE credit opportunity is jointly provided by the Postgraduate Institute for Medicine and NIAAA.

    CME/CE Activity — Screen and Assess: Use Quick, Effective Methods

    Released on 5/6/2022
    Expires on 5/10/2023

    Complete CME/CE Post-Test

    Please note that you will need to log into or create an account on CME University in order to complete this post-test.

    Learning Objectives

    After completing this activity, the participant should be better able to:

    • Identify reasons why universal alcohol screening should be performed.
    • List quick and effective screening questions for heavy alcohol use.
    • Describe how to conduct a quick alcohol use disorder (AUD) assessment.

    Contributors

    Contributors to this article for the NIAAA Core Resource on Alcohol include the writers for the full article, the content contributors to subsections, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.

    External Writers and Content Contributors

    Felicia W. Chi, MPH
    Senior Data Consultant Center for Addiction and
    Mental Health Research, Kaiser Permanente
    Division of Research, Oakland, CA

    Constance M. Weisner, DrPH, MSW
    Research Scientist, Kaiser Permanente Division
    of Research, Oakland, CA
    Professor emeritus at the Department of
    Psychiatry, University of California,
    San Francisco, CA

    NIAAA Content Contributors

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    External Reviewers

    Douglas Berger MD, MLitt
    Staff Physician, VA Puget Sound
    Associate Professor of Medicine
    University of Washington, Seattle, WA

    Katharine A. Bradley, MD, MPH
    Senior Investigator Kaiser Permanente,
    Washington Health Research Institute,
    Seattle, WA

    Mary F. Brolin, PhD
    Senior Scientist Institute for Behavioral
    Health, Heller School for Social Policy and
    Management, Brandeis University, Waltham,
    MA

    Randall Brown MD, PhD
    Professor, School of Medicine
    & Public Health,
    University of Wisconsin, Madison, WI

    H. Westley Clark, MD, JD, MPH
    Dean's Executive Professor of Public Health,
    Santa Clara University, Santa Clara, CA

    Constance M. Horgan, ScD
    Professor and Director, Institute for
    Behavioral Health, Heller School for Social
    Policy and Management,
    Brandeis University, Waltham, MA;
    Co-Director, Schneider Institutes for Health
    Policy and Research,
    Brandeis University, Waltham, MA

    Evette J. Ludman, PhD
    Senior Research Associate (Retired),
    Kaiser Permanente Washington Health
    Research Institute, Seattle, WA

    NIAAA Reviewers

    George F. Koob, PhD
    Director, NIAAA

    Patricia Powell, PhD
    Deputy Director, NIAAA

    Lorenzo Leggio, MD, PhD
    NIDA/NIAAA Senior Clinical Investigator and Section Chief;
    NIDA Branch Chief;
    NIDA Deputy Scientific Director;
    Senior Medical Advisor to the NIAAA Director

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    Editorial Team

    NIAAA

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    Contractor Support

    Elyssa Warner, PhD
    Co-Lead Technical Editor,
    Ripple Effect

    Daria Turner, MPH
    Reference and Resource Analyst,
    Ripple Effect

    To learn more about CME/CE credit offered as well as disclosures, visit our CME/CE General Information page. You may also click here to learn more about contributors.

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