Screening for Problem Drinking
Impact on Physician Behavior and Patient Drinking Habits
Joseph Conigliaro, MD, MPH, Richard P. Lofgren, MD, MPH, Barbara H. Hanusa, PhD
drinking on medical residents and their patients.
To assess the effect of a screen for problem
Descriptive cohort study.
Veterans Affairs Medical Clinic.
uled visit (
tients scored positive.
Patients were screened 2 weeks before a sched-
714). Physicians were informed if their pa-
MEASUREMENTS AND MAIN RESULTS:
alcohol use was documented through patient interview and
chart review. Self-reported alcohol consumption was re-
corded. Of 236 current drinkers, 28% were positive for prob-
lem drinking by the Alcohol Use Disorders Identification Test
(AUDIT). Of 58 positive patients contacted at 1 month, 78%
recalled a discussion about alcohol use, 58% were advised to
decrease drinking, and 9% were referred for treatment. In 57
positive patient charts, alcohol use was noted in 33 (58%),
and a recommendation in 14 (25%). Newly identified patients
had fewer notations than patients with prior alcohol prob-
lems. Overall, 6-month alcohol consumption decreased in
both AUDIT-positive and AUDIT-negative patients. The pro-
portion of positive patients who consumed more than 16
drinks per week (problem drinking) decreased from 58% to
49%. Problem drinking at 6 months was independent of phy-
sician discussion or chart notation.
Physician discussion of
a majority of patients who screened positive for alcohol prob-
lems but less often offered specific advice or treatment. Fur-
thermore, residents were less likely to note concerns about
alcohol use in charts of patients newly identified. Finally, a
screen for alcohol abuse may influence patient consumption.
Resident physicians discussed alcohol use in
J GEN INTERN MED 1998;13:251–256.
alcohol abuse; problem drinking; screening;
drink or have drunk alcohol, and as many as 14% report
a history of abuse or dependence.
tributor to hospital and emergency department visits, ac-
cidents, and lost productivity.
greater severity and with a higher mortality, is increas-
ingly associated with alcohol use.
Problem drinkers are patients whose pattern of alco-
hol consumption does not fulfill DSM-IV criteria for alco-
hol abuse or dependence but is characterized by a suffi-
ciently large intake to have associated problems of health
and social functioning.
Problem drinkers develop minor
medical problems that they present to primary care pro-
It is in this setting that early treatment of alcohol
problems has been recommended.
lcohol problems are a serious medical and public
health issue. Ninety percent of U.S. adults currently
Alcohol is a major con-
Trauma, usually of a
Results of previous
studies provide evidence that simple and early interven-
tion can persuade problem drinkers to reduce their intake
to low-risk levels and use fewer medical resources.
The U.S. Preventive Services Task Force has recom-
mended screening for alcohol abuse by health care work-
However, primary care providers often fail to recog-
nize alcohol problems especially in problem drinkers.
This failure has led to recent efforts focusing on improv-
ing the early detection of patients with alcohol problems
by students, residents, and primary care providers.
Identification of alcohol problems in primary care pa-
tients is a first step in dealing with this prevalent prob-
lem. Many physicians, however, feel they do not possess
the skills necessary to initiate management in this set-
We were interested in how residents in a Veter-
ans Affairs (VA) primary care clinic would respond when
their patients screen positive with the Alcohol Use Disor-
ders Identification Test (AUDIT), a screen for problem
drinking as well as more severe alcohol problems. We also
examined the impact of the program on their patients.
Patients were recruited from the Pittsburgh/Oakland
VA Medical Center, a major medical and surgical tertiary
care center for Western Pennsylvania, Ohio, and West Vir-
ginia and a major teaching affiliate of the University of
Pittsburgh. The Institutional Review Boards of both the
Pittsburgh VA and the University of Pittsburgh approved
the protocol. Before instituting the screening program, we
obtained informed consent from residents to allow screen-
ing of their patients.
We randomly telephoned one of every four patients
scheduled to see a second- or third-year internal medicine
resident from April 1 through October 31, 1992, two weeks
prior to their clinic visit. We included patients able to be
contacted by telephone, who were planning to keep their
Received from the Section of General Internal Medicine, VA
Pittsburgh (Pa.) Health Care System (JC), the Center for Re-
search on Healthcare, University of Pittsburgh (Pa.) Medical
Center (JC, BHH); and the Division of General Internal Medi-
cine, Medical College of Wisconsin, Milwaukee (RPL).
Presented in part at the Society of General Internal Medicine
National Meeting, April 1994.
Address correspondence and reprint requests to Dr.
Conigliaro: VA Pittsburgh Health Care System (11A), Section of
General Medicine, University Drive C, Pittsburgh, PA 15240.
Conigliaro et al., Screening for Problem Drinking
appointment, and who were able to complete the inter-
view. If the telephone service was disconnected, or if the
patient could not be contacted after three attempts at
three different times, then the interviewer proceeded to
the next fourth patient in sequence. After each subject
agreed to participate in the study, audiotaped informed
consent was obtained.
From the 3,434 scheduled visits, we telephoned 779
veterans. Sixty-five (8.3%) of the patients refused to par-
ticipate because they were unwilling to perform the tele-
phone survey. We administered a lifestyle risk assessment
that included the AUDIT, a measure of alcohol consump-
tion, and other questions on lifestyle habits (smoking, ex-
ercise, and diet). The AUDIT is a 10-item questionnaire
measuring alcohol consumption, dependence symptoms,
and personal and social problems associated with alcohol
The AUDIT identifies a current, alcohol-
related problem in patients who score 8 or more of a pos-
sible 40 points with a sensitivity of 96% and a specificity
We measured alcohol consumption by self-re-
port asking separate questions for quantity and frequency
in the consumption of beer, wine, and spirits. This
method of reporting alcohol consumption possesses good
agreement with other methods such as drinking diaries
and allows for direct conversion to standard drinks (1.5 oz
of spirits, 12 oz of beer, or 5 oz of wine).
Patients were analyzed by degree of consumption in
two ways. First, we classified patients as problem drink-
ers based on weekly consumption of more than 16 drinks
per week as reported by Sanchez-Craig et al.
similar to the 14 drinks per week recommended in the
National Institute on Alcohol Abuse and Alcoholism
The Physicians’ Guide to Helping Pa-
tients with Alcohol Problems
tients as those who drank more or less than 35 drinks per
week, which is the level of consumption used to validate
the AUDIT screen.
The principal investigator (JC) notified the residents
of all AUDIT-positive patients through a letter placed on
the chart at the time of the clinic appointment. The letter
included information regarding the AUDIT. No informa-
tion regarding study hypothesis was included. Sixty-one
patients (94%) kept their clinic appointments, and only
their data were used in the follow-up analyses. We inter-
viewed 58 (91%) of the AUDIT-positive patients by tele-
phone 1 month after the index clinic visit to assess
whether any discussion of alcohol problems took place, if
any intervention was planned, and if so, whether it was
implemented. We resurveyed 215 (91%) of the original
current drinkers by telephone at 6 months. We collected
self-report data on number of emergency department vis-
its, and number of inpatient hospital days over the last 6
months and also asked patients to specify if the visits or
hospital days were alcohol related.
We reviewed patient charts to establish if an alcohol-
related diagnosis existed prior to the index visit, and
whether an alcohol problem and treatment were noted at
We further subdivided pa-
the index visit. A patient was considered to have a history
of alcohol-related diagnosis if there was any notation of
alcoholism, alcohol abuse, or admission for an alcohol-
related problem such as alcoholic hepatitis in the chart
prior to the index visit. In addition, we searched the VA
Patient Treatment File for diagnosis codes associated with
alcohol in the last 5 years. Finally, we recorded the num-
ber of medical diagnoses in each problem list. Number of
medications, gamma glutamyl transferase (GGT), hemo-
globin, and mean corpuscular volume (MCV) measured
over the past 2 years were obtained from a hospital com-
Differences in demographics, clinical factors, and
drinking behavior between AUDIT-positive and AUDIT-
negative drinkers, problem drinkers, and nonproblem
drinkers, and those with and without a prior history of al-
cohol abuse were measured with
ables and Mann-Whitney
sures. Comparisons across time were done with McNemar’s
test for categorical variables, Wilcoxon signed-rank, Fried-
man’s test for continuous measures and repeated mea-
sures analysis of variance (ANOVA) of the ranks of total
consumption across time. Nonparametric tests were used
for measures of consumption because of the highly
skewed nature of the data.
for categorical vari-
tests for continuous mea-
Of the 714 patients who completed the questionnaire,
236 (33%) reported current drinking. Sixty-five of the cur-
rent drinkers (28%) were AUDIT-positive, representing 9%
of those who completed the survey. Demographic and
clinical characteristics of AUDIT-positive and AUDIT-
negative patients are displayed in Table 1. Positive pa-
tients were younger, more often received disability in-
come, had more medical comorbid conditions, were on
more medications, and had higher GGT levels than nega-
tive patients. Thirty percent of patients in the positive
group had GGT levels in the abnormal range (
compared with 13% in the negative group. They also con-
sumed more alcohol, were more likely to drink more than
16 drinks per week, and to have a prior alcohol-related di-
agnosis. At the 1 month interview, 45 (78%) of the AUDIT-
positive patients recalled at least some discussion about
alcohol by their physician at the index visit. Thirty-four
(58%) of these patients specifically recalled being told to
“cut down,” and 5 (9%) reported being referred for outside
intervention. Chart review was possible for 57 (89%) of
the positive patients. Residents noted the results of the
screen of the current alcohol problem in 33 (58%) of these
charts and a specific recommendation in 14 (25%) of the
A comparison of the patient reports and the physi-
cian notes was possible for 52 AUDIT-positive patients.
Volume 13, April 1998
There was agreement about the presence or absence of a
discussion of alcohol problems in 37 (71%) of these pa-
tients. Patients were more likely to remember discussions
than physicians were to note discussions (McNemar’s
.007). AUDIT-positive patients without previous
notation of alcohol problems in the record recalled a dis-
cussion about alcohol less often than those with a prior
diagnosis (61% vs 88%,
likely to have had a notation about alcohol abuse in the
index visits (17% vs 86%
tic regression with AUDIT-positive patients that consid-
ered previous mentioning of alcohol problems in the pa-
tient chart, number of medical diagnoses, patient age
60 years), level of current drinking, patient GGT level,
patient income, and education levels, only previous nota-
tion of an alcohol problem was a significant predictor of
current notation (odds ratio [OR] 27.6; 95% confidence in-
terval [CI] 6.6, 115.9).
After 6 months, the median number of drinks per
week decreased from 4.25 to 2.5 (ANOVA of the ranks,
.0001) with the proportion of patients drinking more
than 16 drinks per week decreasing from 23% to 17%
.01, McNemar’s test) for all patients who were cur-
rent drinkers. Table 2 compares patient drinking behavior
over 6 months. Significant decreases in consumption
were seen in AUDIT-positive patients (
test of the interaction). The proportion of AUDIT-positive
.05) and were less
.0001). In a logis-
.0001, for the
patients who were drinking in the problem drinking range
decreased from 58% to 49% at the end of 6 months (Mc-
.33). AUDIT-negative patients also showed
a nonsignificant decrease in their consumption with me-
dian number of drinks decreasing from 3.75 drinks per
week initially to 1.75 drinks per week at the 6-month in-
terview. The 16 patients who were AUDIT-negative but re-
ported consuming more than 16 drinks per week at en-
rollment showed a significant decrease in consumption
over the 6-month period from a median of 21 drinks per
week to 6 drinks per week (
The first three AUDIT questions deal specifically with
the frequency and quantity of alcohol consumption. When
the responses to these questions were studied across
time, they indicated that the frequency of drinking de-
creased slightly for all levels of frequency but quantity of
alcohol consumed on each occasion decreased for the
lighter drinkers (
4 drinks per occasion) more than for
heavier drinkers (
4 drinks per occasion). On the ques-
tion of how often 6 or more drinks are consumed, more of
those who reported fewer incidents (less than once a
month) initially reported a decrease at 6 months than
those who initially reported more incidents (once a month
For AUDIT-positive patients, there were no univariate
relations between physician notation or patient recall of
alcohol discussion and subsequent decreases in consump-
Table 1. Characteristics of AUDIT-Negative and AUDIT-Positive Patients
Mean age, years
High school graduate, %
Annual household income level,
Social security and disability
Median medical diagnoses
Mean GGT, IU/L
Abnormal GGT, %
Median drinks per wk
16 Drinks per wk,
17–35 Drinks per wk,
35 Drinks per wk,
History of alcohol abuse,
Three patients did not complete the entire AUDIT questionnaire.
Value based on ANOVA.
Values based on Mann–Whitney
GGT data were lacking for 33 patients.
Values based on
Conigliaro et al., Screening for Problem Drinking
tion. When initial AUDIT status, initial problem drinking
status, number of comorbid medical and psychiatric ill-
nesses, previous history of alcohol-related problems, pa-
tient recall of advice to decrease drinking, or physician
notation of alcohol problem and total quantity of alcohol
consumed at enrollment were used in a multivariate logis-
tic regression to model 6-month problem drinking status,
only initial AUDIT (OR 8.1; 95% CI 3.0, 21.5) and initial
consumption of more than 16 drinks per week (OR 8.8;
95% CI 3.3, 23.6) were significant. When only AUDIT-
positive patients were used in the same multivariate model,
only the measure of total quantity consumed at enrollment
was a significant predictor. As shown in Table 3, there
were no differences related to initial AUDIT status in
emergency department use or hospital admissions at the
We found that a majority of AUDIT-positive patients
recalled a discussion about alcohol problems by their res-
ident physician. The majority of the discussions consisted
of advice to decrease use and much less often involved a
specific recommendation for more traditional treatment.
Nevertheless, there appeared to be a modest reduction in
patient alcohol consumption over 6 months.
Our finding of a 78% discussion rate in screen-
positive patients was comparable to that in a previous
study. Schorling et al. screened patients of categorical in-
ternal medicine, primary care internal medicine, and fam-
ily medicine residents for alcohol abuse using the Michi-
gan Alcoholism Screening Test and showed that 60% to
80% of positive patients recalled a discussion of alcohol
abuse by their physician in the past year.
resident intervention consisted mostly of advice to “cut
down” in 58% of AUDIT-positive patients, but referral to
other therapy occurred in less than 25%. This finding is
In our study,
lower than that found in the inpatient setting, where
Moore noted that when the diagnosis of alcohol abuse
was made, treatment was instituted 50% to 75% of the
If outpatients are more likely problem drinkers,
then they may lack clinical evidence of an alcohol-related
problem and physicians might be less likely to offer other,
more intensive traditional treatment.
Newly diagnosed patients in our study were less
likely to recall a discussion, and physicians were less
likely to note an alcohol-related problem. These patients
may be problem drinkers who lack the “clinical” evidence
of an alcohol-related problem. In a similar study, Buchs-
baum et al. administered the alcohol module of the Diag-
nostic Interview Schedule to patients in a medical clinic at
an urban university teaching hospital staffed by interns
and residents and studied patient and physician charac-
teristics that influence detection of problem drinking.
Resident physicians, unaware of the interview results,
noted alcohol problems in the chart of 49% of patients
who met criteria for current alcohol abuse or dependence.
Previous medical record reference of alcohol problems,
number of concurrent medical problems, patient gender,
Table 2. Drinking Behavior at Initial Interview and at 6 Months
Drinking Behavior Initial AUDIT Positive Initial AUDIT Negativep Value
Median drinks per wk at initial interview (range)
16 Drinks per wk,
17–35 Drinks per wk, n (%)
?35 Drinks per wk, n (%)
Median drinks per wk 6 mo (range)
?16 Drinks per wk, n (%)
17–35 Drinks per wk, n (%)
?35 Drinks per wk, n (%)
AUDIT-positive score at initial interview (%)
AUDIT-positive score at 6 mo (%)
*Results reported for patients with complete data at initial and 6-month interviews; n ? 209 (55 AUDIT positive, 154 AUDIT negative) for con-
sumption measures and n ? 215 (55 AUDIT positive, 160 AUDIT negative) for AUDIT measure.
†Results of a 2 (AUDIT positive/negative) ? 2 (initial/6 mo) repeated measures analyses of the ranks of the dependent measure indicated
that the AUDIT-positive group had a significant decrease over time and the AUDIT-negative group did not. The AUDIT-positive group also had
a significantly higher level of drinking at the initial interview.
‡p Values based on ?2 statistic except for comparison of initial and 6-month AUDIT scores, which used McNemar’s statistic.
Table 3. Health Care Utilization During the 6-Month
(n ? 54)
(n ? 156)
Emergency department use, n (%)
Number of visits
Hospital admissions, n (%)
Number of days
recommended, n (%)
Completed or current
Volume 13, April 1998
and gastrointestinal problems were associated with detec-
tion of alcohol problems by residents. Our notation rate of
58% resulted when physicians were made aware of a cur-
rent problem. We also found that prior medical record no-
tation was the strongest predictor of current notation in
the chart. The association of prior medical record notation
in both studies support the theory that residents depend
on prior labeling with alcohol diagnoses in making cur-
rent alcohol-related diagnoses.
Six months after screening, patients reported a de-
crease in alcohol consumption and were less likely to
drink in the problem range. This was due primarily to de-
creased consumption among the AUDIT-positive group
and problem drinkers. However, screen-positive patients
who recalled a discussion about alcohol with their doctor
or for whom physicians made a note in the chart had a
similar decrease in their alcohol consumption compared
with those without a reported discussion or notation. The
rate of utilization of alcohol-related and non-alcohol-related
health care services was low in all patients and did not
explain the decrease in consumption.
These overall findings suggest that a simple screen-
ing program may act as a brief intervention for problem
drinkers. A simple screen or reminder has been shown to
reduce consumption and adverse outcomes from drinking
in a number of studies.31 Wallace et al., screening general
practitioners’ practices, found an overall reduction of 24%
in the proportion of patients who reported excessive levels
of consumption at 12 months.10 Most recently, Fleming et
al. reported a 20% reduction in alcohol use among control
patients in a study evaluating the efficacy of brief physi-
cian advice in reducing alcohol use and health care utili-
zation in problem drinkers.12 Patients in our study who
were AUDIT-negative but consumed alcohol in the prob-
lem range also had a significant decrease in their con-
sumption although we did not specifically identify them to
their physicians. The reasons for these reductions include
regression to the mean, historical changes in alcohol use,
and the intervention effect of the screen and the data col-
lection procedures independent of physician involvement.
There are several limitations to our study. First, the
patient sample was derived from a single VA hospital,
which may limit the generalizability of our results. Veter-
ans may possess unique medical and psychosocial co-
morbidities that increase the prevalence of alcohol prob-
lems or make their diagnosis difficult to establish. Our
prevalence, although low, is in the range of earlier stud-
ies, as is our rate of physician recognition.14,28 Our lower
rate of alcohol problems and higher rate of nondrinkers
may be a reflection of the older age of our population. Pa-
tients who were heavier drinkers may have succumbed
from complications associated with drinking or other co-
morbid conditions. Residents cared for the patients in our
study so these results may not be applicable to other
health care providers. The issue of alcohol abuse and
early treatment, however, should be more salient during
training and thus resident rates of discussion might be
higher than with physicians in practice. Residents are
also caring for fewer patients per clinical session.
We used a quantity-frequency method to assess aver-
age level of consumption. Such methods may underesti-
mate consumption especially when patients have days of
excessive or heavy alcohol use that deviate substantially
from their average daily consumption.32 However, when
average consumption was sought, this method produced
results similar to those of a study using a more sensitive
time-line method.32 Finally, we used a telephone-based
screen that may have biased patient responses. Prior
comparisons between telephone interviews and face-to-
face interviews found that women tended to underreport
consumption in face-to-face interviews, but no difference
was seen in men.33
Despite these limitations, we believe our study has
important implications. First, we showed that given the
knowledge of a positive alcohol screen, residents dis-
cussed alcohol problems in a majority of patients, how-
ever, this occurred less often for patients without a prior
history of alcohol abuse. Second, a simple screen for alco-
hol problems may be enough of an intervention to de-
crease alcohol consumption in patients. This last finding
contributes to the growing body of literature supporting
the importance of a brief intervention. Given these find-
ings, clinic directors should consider implementing a sys-
tematic screening program to identify alcohol problems
and decrease overall drinking rates in their patients.
The authors thank Jeff Whittle, MD, MPH, for providing data
from the VA Patient Treatment File and Jeannette Gibbon for
performing the interviews.
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