Brief Approaches to Alcohol Screening: Practical Alternatives for Primary Care

Journal of General Internal Medicine (Impact Factor: 3.42). 08/2009; 24(7):881-3. DOI: 10.1007/s11606-009-1014-9
Source: PubMed


Available from: Emily C Williams, Dec 27, 2013
Brief Approaches to Alcohol Screening: Practical Alternatives
for Primary Care
Katharine A. Bradley, MD, MPH
, Daniel R. Kivlahan, PhD
, and Emily C. Williams, MPH
Health Services Research & Development (HSR&D), Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA;
Primary and
Specialty Medical Care Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA;
Department of Medicine,
University of Washington, Seattle, WA, USA;
Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA;
Department of Health Services, University of Washington, Seattle, WA, USA.
J Gen Intern Med 24(7):8813
DOI: 10.1007/s11606-009-1014-9
© Society of General Internal Medicine 2009
rief alcohol counseling is one of the most important
preventive services we can offer primary care patients. As
many as 20% of general medicine outpatients have unhealthy
drinking patterns (definitions
in box) and can benefit from
brief counseling interventions.
The US Preventive Services
Task Force (USPSTF) recommends routine alcohol screening
followed by brief interventions (BI),
and in 2006, the National
Commission on Prevention Priorities (NCPP) ranked alcohol
screening and BI in the top five U.S. prevention priorities.
NCPP is funded by the US Centers for Disease Control and
Agency for Healthcare Research and Quality to prioritize
USPSTF recommendations based on the clinically preventable
burden of disease and cost effectiveness, and alcohol screening
and brief counseling was one of the few preventive interven-
tions that NCPP found to be cost saving.
However, the NCPP
also noted that alcohol screening and counseling were among
the least implemented recommended interventions studied,
and efforts to implement alcohol screening and BI outside
research settings have made slow progress.
The first step in implementation of brief alcohol counseling
is offering all patients routine alcohol screening. Provider
incentives appear to facilitate implementation of screening for
unhealthy drinking.
In an effort to encourage screening for
unhealthy drinking, the American Medical Association (AMA)
has recently developed new Current Procedural Terminology
(CPT) codes, as well as a new performance measure for alcohol
screening. In 2009, screening for unhealthy alcohol use is one
of the measures for the Physician Quality Reporting Initiative
(PQRI) implemented by the Center for Medicare and Medicaid
Services (CMS), which allows providers to earn an incentive
payment of 2% of their total allowed charges for covered
professional services.
Providers and health care systems wishing to implement
routine alcohol screening must first select a validated ques-
tionnaire, since there is currently no valid laboratory screen for
unhealthy drinking. However, choosing which alcohol screen-
ing questionnaire to use is not simple. Many alcohol screening
questionnaires have been validated over the past 20 years, but
those used in randomized trials of BI have included 710
questions. Given multiple primary care agendas, briefer
approaches to screening make routine alcohol screening more
practical. However, a favorite questionnaire in the US, the 4-
item CAGE
(Table 1), is not well-suited to identify patients
who can benefit from brief counseling unless questions about
alcohol consumption are added.
The CAGE questionnaire
is a valid screen for alcohol use disorders, but, as pointed out
by Smith and colleagues in this issue of JGIM,
the CAGE is
not an effective screen for patients with risky drinking who
have not experienced problems due to drinking. Moreover, the
CAGE asks about drinking ever in the patients life, and many
patients will screen positive who no longer drink alcohol.
Thus, the CAGE should not be used alone for identifying
patients who benefit from brief alcohol counseling.
Two brief approaches to screening for unhealthy drinking
have been validated over the past decade (Table 1), each of
which has strengths in different settings. One approach is
single question screens like that validated in the article by
Smith and colleagues in this issue of JGIM.
The other is the
first three questions of the Alcohol Use Disorders Identification
Test (AUDIT) developed by the World Health Organization
the AUDIT-C. Both single question screens and the
AUDIT-C take advantage of the strong association between
drinking 5 or more drinks on an occasion and adverse
consequences of drinking.
Moreover, both brief approaches
to screening have performed similarly in US clinical sam-
Although the study by Smith et al. suggested the
AUDIT-C might have a lower sensitivity than the single-question
screen recommended by NIAAA, their study included 54%
women and the cut-point they used for the AUDIT-C ( 4) is
relatively insensitive in women (38% to 57%).
Single-question alcohol screens, such as that proposed by
NIAAA (How many times in the past year have you had 4
(women)/5 (men) or more drinks?),
are clearly the optimal
approach to integrating screening into clinical history-taking.
Single-question screens are brief, easily remembered, and
require no scoring. Any report of drinking 4 or more drinks
on an occasion for women or 5 or more for men is a positive
screen. Moreover, the frequency of drinking at these levels is
strongly associated with risk for alcohol dependence,
tially helping providers to assess patients who will benefit from
referral to specialized addictions treatment. For all these
reasons, all medical students and general medicine providers
should commit to memory one single-question alcohol screen
for unhealthy drinking (Table 1).
However, single-item approaches to alcohol screening pro-
vide little information on typical or average consumption, an
Published online June 3, 2009
Page 1
important component of risky drinking. Women and men can
drink up to 3 and 4 drinks daily, respectively, and honestly
answer never to single question screens, thereby screening
negative even though drinking 34 drinks daily is associated
with increased risk for a number of medical problems includ-
ing hypertension, liver disease, stroke, trauma, and breast
cancer. In addition, many providers are more comfortable first
assessing whether patients drink alcohol at all and then
asking a single question screen (making screening a two-step
approach). In this situation, a validated standard question
should be used such as, Do you sometimes have a drink
containing alcohol?
or, How often did have you have a
drink containing alcohol in the past year? which is the first
question of the AUDIT-C. Non-standard approaches can miss
up to 24% of drinkers.
The three-item AUDIT-C has several advantages for health
care systems, clinics, or practices implementing routine
alcohol screening with the aid of patient-completed health
questionnaires, computerized prompts in an electronic medi-
cal record, or web-based personal health risk assessments.
The AUDIT-C provides clinicians with information on typical
drinking as well as the frequency of heavy drinking, thus
providing information on both components of risky drinking
(definitions box). The AUDIT-C score (012 points) also reflects
severity of symptoms due to unhealthy drinking.
In addition,
AUDIT-C scores have been associated with increased risk for
medication non-adherence (AUDIT-C scores 4),
zations for liver disease, upper gastrointestinal bleeding, or
pancreatitis ( 6 for men in general; 4 for men under
50 years old),
fractures ( 8),
and death in men under
50 years old ( 10).
Therefore, AUDIT-C scores can assist
providers to offer patients personalized feedback on alcohol-
related risks. Such feedback is an essential component of
evidence-based brief interventions, along with explicit advice to
abstain or drink below recommended limits.
Furthermore, in
a recent meta-analysis the AUDIT-C performed as well as the
full 10-item AUDIT for identification of unhealthy alcohol use
in primary care at recommended cut-points: AUDIT-C sensi-
tivity 0.86 (0.79 0.91) and specificity 0.78 (0.620.89) com-
pared with the AUDIT sensitivity 0.81 (0.750.85) and
specificity 0.83 (0.790.87),
with no significant difference in
their overall accuracy. Finally, when AUDIT-C scores from
annual screening are stored in electronic medical records, they
may be used to monitor changes in risk over time.
However, in settings without electronic health records or
web-based methods t o facilitate and automate s creening,
scoring the 3 AUDIT-C items (each scored 04) may be a
barrier, particularly if the number of response options to
AUDIT-C questions is increased.
Another important limita-
tion is that patients can screen positive despite reporting
drinking within recommended limits. The screening cut-points
of the AUDIT-C are based on empiric findings from interview
validation studies and take into account the fact that patients
tend to under-report their typical drinking on AUDIT-C ques-
tions #12. Therefore, patients reporting 1 drink daily, a level
often associated with improved cardiovascular health, can
screen positive with an AUDIT-C score of 4 by scoring 4 points
on AUDIT-C question #1 and 0 points on AUDIT-C questions
#23. Thus, while the AUDIT-C score is a valid and effective
screen, and a useful reflection of overall alcohol-related risks,
clinicians must be educated that the reported consumption on
AUDIT-C questions #12 tends to underestimate typical
drinking. Clinicians might be urged to view the AUDIT-C score
as a marker similar to hemoglobin A1c, a tool which does not
directly measure specific patient behaviors but provides useful
information on patients alcohol-related risks based on the
epidemiologic evidence.
In summary, two brief approaches to alcohol screening
single question screens and the AUDITCperform similarly
for identifying unhealthy alcohol use and are likely most useful
in different settings. All medical providers should commit to
memory a validated single question screen for use in medical
interviews. The question recommended by NIAAA and validat-
ed in this edition of JGIM is one such question and provides
Table 1. Screening Questionnaires
CAGE Questionnaire
Screens for alcohol use disorders only; not useful for screening for risky drinking;
possible scores 04; 2 points typically considered a positive screen for alcohol use disorders.
CHave you ever felt you ought to
Cut down on your drinking?
AHave people
Annoyed you by criticizing your drinking?
GHave you ever felt bad or
Guilty about your drinking?
EHave you ever had a drink first thing in the morning (
Eye-opener) to steady your nerves or get rid of a hangover?
Single Question Alcohol Screens
Screen for the entire spectrum of unhealthy drinking from risky drinking to alcohol use disorders.
How many times in the past year have you had X or more drinks? (X = 4 for women, 5 for men; ever = positive screen)
When was the last time you had more than X drinks in a day? (X = 4 for women, 5 for men; < 3 months = positive screen)
On any single occasion in the past 3 months have you had more than 5 drinks containing alcohol? (ever = positive screen)
How often did you drink 6 or more drinks on an occasion in the past year? (ever = positive screen)
How often did you drink 4 or more drinks on an occasion in the past year? (gender-specific version of the question above; ever = positive screen)
The Alcohol Use Disorders Identification Test Consumption Questions (AUDIT-C)
Screens for the entire spectrum of unhealthy drinking from risky drinking to alcohol use disorders;
possible scores 012; 3 points for women or 4 for men typically considered a positive screen.
1. How often have you had a drink containing alcohol in the last year? Consider a drink to be a can or bottle of beer, a glass of wine, a wine
cooler, or one cocktail or shot of hard liquor (like scotch, gin, vodka). Never (0 points); monthly or less (1); 24×/month (2); 23×/week (3);
4 days/week (4).
2. How many drinks containing alcohol did you have on a typical day when you were drinking in the last year? I do not drink (0 points); 12
drinks (0); 34 drinks (1); 56 drinks (2); 79 drinks (3); 10 or more drinks (4).
3. How often in the last year have you had 6 or more drinks on one occasion? Never (0 points); < monthly (1); monthly (2); weekly (3); daily or
almost (4)
882 Bradley et al.: Brief Approaches to Alcohol Screening JGIM
Page 2
useful information on the frequency of episodic drinking above
recommended daily limits, which is strongly associated with
the risk of alcohol dependence. When health care systems
implement routine alcohol screening using standardized or
automated approaches, the AUDIT-C can provide added useful
information on patients self-reported typical drinking, as well
as additional information on the likely burden of alcohol-
related symptoms and alcohol-related health risks.
Corresponding Author: Katharine A. Bradley, MD, MPH; VA Puget
Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle,
WA 98101, USA (e-mail:
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Box 1. Definitions
Unhealthy drinking refers to the entire spectrum from risky drinking
to severe alcohol dependence.
Risky drinking
refers to drinking at levels associated with increased
risk for harm:
For men: over 14 drinks per week or 5 or more drinks on any occasion
For women: over 7 drinks per week or 4 or more drinks on any occasion.
Alcohol use disorders are defined by DSM-IV
as alcohol abuse or
dependence, although recent evidence suggests that symptoms
designated as criteria for alcohol abuse may be indistinguishable from
those designated as criteria for alcohol dependence.
883Bradley et al.: Brief Approaches to Alcohol ScreeningJGIM
Page 3
  • Source
    • "Quantity and frequency of alcohol misuse were assessed via the AUDIT-C. The AUDIT-C is a validated screening tool for alcohol misuse and has been used for routine screening in the primary care setting (Bradley et al., 2009; Bush et al., 1998). The AUDIT-C comprises the consumption questions of the original 10-item AUDIT (Babor and Grant, 1989) and performs similarly to the full AUDIT in terms of identifying the spectrum of alcohol misuse (Kriston et al., 2008; Reinert and Allen, 2007). "
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    • "All patients met diagnostic criteria for Crohn's disease or ulcerative colitis [10]. The criteria for exclusion were age less than 18 years, pregnancy, or alcoholism, the latter defined as a CAGE score of > 1 [11]. Faria et al Gastroenterol Res. "
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    • "Scores 4 in men or 3 in women indicate positive screens for hazardous alcohols use. We dichotomized this variable as nonhazardous alcohol use versus hazardous alcohol use, and allocated 1 point for the latter [38, 39]. Participants reported the average number of hours per night spent sleeping over the previous month, and 1 point was allocated for an average of <7 hours of sleep or >9 hours of sleep, as previously established as a risk factors for health [40]. "
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