Abstract
Primary medical care should include routine alcohol screening to identify patients with unhealthy alcohol use, whether an alcohol use disorder or risky drinking. Screening should include all adult primary care patients as well as adolescents. Although it is important that screening be done with a validated instrument, there are a number of similarly accurate alcohol screening questionnaires for identifying the entire spectrum of unhealthy drinking, and some of them are very brief. We believe that primary care clinicians should commit two validated questions to memory: one to assess any alcohol use and one single-item alcohol screening question (SASQ). However, in settings with EMRs and systems for universal screening, we favor use of the AUDIT-C because of the information it provides on reported typical drinking and on the severity of unhealthy drinking, as well as the utility of a scaled marker for measuring the severity of unhealthy alcohol use and changes over time. Finally, primary care clinicians and others conducting screening must all be carefully trained about recommended drinking limits and risks associated with drinking above them, the purpose of alcohol screening and the efficacy of brief alcohol interventions, including practicing asking validated screening questions in a comfortable manner.
Keywords
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
Willenbring ML, Olson DH. A randomized trial of integrated outpatient treatment for medically ill alcoholic men. Arch Intern Med. 1999;159(16):1946–1952.
Willenbring ML. Medications to treat alcohol dependence: adding to the continuum of care. JAMA. 2007;298(14):1691–1692.
National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: a clinician’s guide (updated 2005 edition). Washington, DC: National Institutes of Health, U.S. Department of Health and Human Services; 2007. NIH Publication 07-3769.
Ahmed AT, Karter AJ, Liu J. Alcohol consumption is inversely associated with adherence to diabetes self-care behaviours. Diabet Med. Jul 2006;23(7):795–802.
Ahmed AT, Karter AJ, Warton EM, Doan JU, Weisner CM. The relationship between alcohol consumption and glycemic control among patients with diabetes: the Kaiser Permanente Northern California Diabetes Registry. J Gen Intern Med. 2008;23(3):275–282.
Bryson CL, Au DH, Sun H, Williams EC, Kivlahan DR, Bradley KA. Alcohol screening scores and medication nonadherence. Ann Intern Med 2008;149(11):795–804.
Tonnesen H, Rosenberg J, Nielsen H, et al. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. Br Med J. 1999;318(7194):1311–1316.
Tonnesen H, Petersen KR, Hojgaard L, et al. Postoperative morbidity among symptom-free alcohol misusers. Lancet. 1992;340(8815):334–337.
Harris AH, Reeder R, Ellerbe L, Bradley KA, Rubinsky AD, Giori NJ. Preoperative alcohol screening scores: association with complications in men undergoing total joint arthroplasty. J Bone Joint Surg Am. 2011;93(4):321–327.
Bradley KA, Rubinsky AD, Sun H, et al. Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery. J Gen Intern Med. 2011;26(2):162–169.
Au DH, Kivlahan DR, Bryson CL, Blough D, Bradley KA. Alcohol screening scores and risk of hospitalizations for GI conditions in men. Alcohol Clin Exp Res. 2007;31(3):443–451.
Chew RB, Bryson CL, Au DH, Maciejewski ML, Bradley KA. Are smoking and alcohol misuse associated with subsequent hospitalizations for ambulatory care sensitive conditions? J Behav Health Serv Res. 2011;38(1):3–15.
Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238–1245.
Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. 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. 2004;140(7):557–568.
Kaner EF, 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.
Kaner E, Beyer F, Dickinson H, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007(2):CD004148.
Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005;352(6):596–607.
Wechsler H, Dowdall GW, Davenport A, Rimm EB. A gender-specific measure of binge drinking among college students. Am J Public Health. 1995;85:982–985.
Bradley KA, Bush K, Davis TD, et al. Binge drinking among femaleVeteransAffairs patients: prevalence and associated risks. Psychol Addict Behav. 2001;15:297–305.
Becker U, Deis A, Sorenson TIA, Gronbaek M, Borch-Johnsen K, Muller CF. Prediction of risk of liver disease by alcohol intake, sex and age: a prospective population study. Hepatology. 1996;23:1025–1029.
Bradley KA, Badrinath S, Bush K, Boyd-Wickizer J, Anawalt B. Medical risks for women who drink alcohol. J Gen Intern Med. 1998;13(9):627–639.
Spurling MC, Vinson DC. Alcohol-related injuries: evidence for the prevention paradox. Ann Fam Med. 2005;3(1):47–52.
Saitz R. Alcohol screening and brief intervention in primary care: absence of evidence for efficacy in people with dependence or very heavy drinking. Drug Alcohol Rev. 2010;29(6):631–640.
Solberg LI, Maciosek MV, Edwards NM. Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness. Am J Prev Med. 2008;34(2):143–152.
American Academy of Family Physicians. Alcohol Misuse. 2011. http://www.aafp.org/online/en/home/clinical/exam/alcoholmisuse.html. Accessed 10 Aug 2011.
American College of Obstetricians and Gynecologists. At-risk drinking and alcohol dependence: obstetric and gynecologic implications. Committee Opinion No. 496. Obstet Gynecol. 2011;118:383–388.
Committee on Substance Abuse. Policy Statement—Alcohol use by youth and adolescents: a pediatric concern. 2010. www.pediatrics.org/cgi/doi/10.1542/peds.2010-0438.
VA Office of Quality and Performance. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders, Version 2.0. http://www.healthquality.va.gov/sud/sud_full_601f.pdf 2009.
Yarnall KSH, Pollak KI, Ostbye T, Krause KM, Micchener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635–641.
Saitz R, Horton NJ, Cheng DM, Samet JH. Alcohol counseling reflects higher quality of primary care. J Gen Intern Med. 2008;23(9):1482–1486.
Bradley KA, Kivlahan DR, Bush KR, McDonell MB, Fihn SD. Variations on the CAGE alcohol screening questionnaire: strengths and limitations in VA general medical patients. Alcohol Clin Exp Res. 2001;25(10):1472–1478.
Cantor SB, Sun CC, Tortolero-Luna G, Richards-Kortum R, Follen M. A comparison of C/B ratios from studies using receiver operating characteristic curve analysis. J Clin Epidemiol. 1999;52(9):885–892.
Steinbauer JR, Cantor SB, Holzer CE, Volk JR. Ethnic and sex bias in primary care screening tests for alcohol use disorders. Ann Intern Med. 1998;129:353–362.
Rubinsky AD, Kivlahan DR, Volk RJ, Maynard C, Bradley KA. Estimating risk of alcohol dependence using alcohol screening scores. Drug Alcohol Depend. 2010;108(1–2):29–36.
Institute of Medicine. Improving the quality of mental health care for mental and substance-use conditions. Washington, DC: The National Academies Press; 2006.
Williams EC, Lapham G, Achtmeyer CE, Volpp B, Kivlahan DR, Bradley KA. Use of an electronic clinical reminder for brief alcohol counseling is associated with resolution of alcohol misuse. J Gen Intern Med. 2010;25(1):11–18.
Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA. 1984;252:1905–1907.
Ewing JA. Screening for alcoholism using CAGE. JAMA. 1998;280:1904–1905.
Buchsbaum DG, Buchanan RG, Centor RM, Schnoll SH, Lawton MJ. Screening for alcohol abuse using CAGE scores and likelihood ratios. Ann Intern Med. 1991;115:774–777.
Bradley KA, Bush KR, McDonell MB, Malone T, Fihn SD. Screening for problem drinking: comparison of CAGE and AUDIT. J Gen Intern Med. 1998;13(6):379–388.
Bradley KA, Maynard C, Kivlahan DR, McDonell MB, Fihn SD. The relationship between alcohol screening questionnaires and mortality among male veteran outpatients. J Stud Alcohol. 2001;62(6):826–833.
Volk RJ, Cantor SB, Steinbauer JR, Cass AR. Item bias in the CAGE screening test for alcohol use disorders. J Gen Intern Med. 1997;12:763–769.
Wallace P, Haines A. Use of a questionnaire in general practice to increase the recognition of patients with excessive alcohol consumption. Br Med J. 1985;290:1949–1952.
Fleming MF, Barry KL. A three-sample test of a masked alcohol screening questionnaire. Alcohol Alcohol. 1991;26(1):81–91.
Selzer ML, Vinokur A, von Rooijen L. A self administered Short Michigan Alcohol Screening Test (SMAST). J Stud Alcohol. 1975;36:117–126.
Zung BJ. Psychometric properties of the MAST and two briefer versions. J Stud Alcohol. 1979;40(9):845–859.
Hedlund JL, Vieweg B. The Michigan Alcoholism Screening Test (MAST): a comprehensive review. J Oper Psych. 1984;15:55–65.
Magruder-Habib K, Stevens HA, Alling WC. Relative performance of the MAST, VAST, and CAGE versus DSM-III-R criteria for alcohol dependence. J Clin Epidemiol. 1993;46(5):435–441.
Pokorny AD, Miller BA, Kaplan HB. The brief MAST: a shortened version of the Michigan Alcoholism Screening Test. Am J Psychiatry. 1972;129(342–345).
Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. Br Med J. 1988;297:663–668.
Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices. JAMA. 1997;277(13):1039–1045.
Fihn SD, McDonell MB, Diehr P, et al. Effects of sustained audit/feedback on self-reported health status of primary care patients. Am J Med. 2004;116(4):241–248.
Babor TF, Grant M. From clinical research to secondary prevention—international collaboration in the development of of the alcohol use disorders identification test (AUDIT). Alcohol Health Res World. 1989;13(4):371–374.
Saunders JB, Aasland OG, Babor TF, De la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption—II. Addiction. 1993;88:791–804.
Babor TF, Higgins-Biddle JC. Brief intervention for hazardous and harmful drinking: a manual for use in primary care. Geneva: World Health Organization; 2001.
Volk RJ, Steinbauer JR, Cantor SB, Holzer CEI. The alcohol use disorders identification test (AUDIT) as a screen for at-risk patients of different racial/ethnic backgrounds. Addiction. 1997;92(2):197–206.
Seale JP, Boltri JM, Shellenberger S, et al. Primary care validation of a single screening question for drinkers. J Stud Alcohol. 2006;67(5):778–784.
Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998;158(16):1789–1795.
Bradley KA, De Benedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res. 2007;31(7):1208–1217.
Bradley KA, Bush KR, Epler AJ, et al. Two brief alcohol-screening tests from the alcohol use disorders identification test (AUDIT): validation in a female veterans affairs patient population. Arch Intern Med. 2003;163(7):821–829.
Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT: the alcohol use disorders identification test: guidelines for use in primary care. 2001. 2nd: http://www.dass.stir.ac.uk/DRUGS/pdf/audit.pdf.
Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary care validation of a single-question alcohol screening test. J Gen Intern Med. 2009;24(7):783–788.
Lapham GT, Achtmeyer CE, Williams EC, Hawkins EJ, Kivlahan DR, Bradley KA. Increased documented brief alcohol interventions with a performance measure and electronic decision support. Med Care. 2010 Sep 28 [E-pub ahead of print].
Lembke A, Bradley KA, Henderson P, Moos R, Harris AH. Alcohol screening scores and the risk of new-onset gastrointestinal illness or related hospitalization. J Gen Intern Med. 2011;26(7):777–782.
Harris AH, Bryson CL, Sun H, Blough D, Bradley KA. Alcohol screening scores predict risk of subsequent fractures. Subst Use Misuse. 2009;44:1055–1069.
Williams EC, Sun H, Chew RB, Chew LD, Blough DK, Au DH, Bradley KA. Association between alcohol screening results and hospitalizations for trauma in veterans affairs outpatients. Am J Drug Alcohol Abuse. Am J Drug Alcohol Abuse. 2012;38:73–80.
Harris AH, Bradley KA, Bowe T, Henderson P, Moos R. Associations between AUDIT-C and mortality vary by age and sex. Popul Health Manag. 2010;13(5):263–268.
Dawson DA, Archer LD. Relative frequency of heavy drinking and the risk of alcohol dependence. Addiction. 1993;88(11):1509–1518.
Taj N, Devera-Sales A, Vinson DC. Screening for problem drinking: does a single question work? J Fam Pract. 1998;46(4):328–335.
Williams R, Vinson DC. Validation of a single screening question for problem drinking. J Fam Pract. 2001;50(4):307–312.
Chang G. Alcohol-screening instruments for pregnant women. Alcohol Res Health. 2001;25(3):204–209.
Russell M, Martier SS, Sokol RJ, et al. Screening for pregnancy risk-drinking. Alcohol Clin Exp Res. 1994;18(5):1156–1161.
Russell M, Martier SS, Sokol RJ, Mudar P, Jacobson SJJ. Detecting risk drinking during pregnancy: a comparison of four screening questionnaires. Am J Public Health. 1996;86:1435–1439.
Dawson DA, Grant BF, Stinson FS, Zhou Y. Effectiveness of the derived alcohol use disorders identification test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population. Alcohol Clin Exp Res. 2005;29(5):844–854.
Knight JR, Sherritt L, Harris SK, Gates EC, Chang G. Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res. 2003;27(1):67–73.
Newton AS, Gokiert R, Mabood N, et al. Instruments to detect alcohol and other drug misuse in the emergency department: a systematic review. Pediatrics. 2011;128(1):e180–192.
Babor TF. The alcohol, smoking and substance involvement screening test (ASSIST): development, reliability and feasibility. Addiction. 2002;91:1183–1194.
Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170(13):1155–1160.
Neumann T, Spies C. Use of biomarkers for alcohol use disorders in clinical practice. Addiction. 2003;98(Suppl 2):81–91.
Center for Substance Abuse Treatment. The role of biomarkers in the treatment of alcohol use disorders. Substance abuse treatment advisory. In: US Department of Health and Human Services SAMHSA, Center for Substance Abuse Treatment. www.samhsa.gov, ed5. US Department of Health and Human Services; 2006.
Miller PM, Anton RF. Biochemical alcohol screening in primary health care. Addict Behav. 2004;29(7):1427–1437.
Fleming MF, Anton RF, Spies CD. A review of genetic, biological, pharmacological, and clinical factors that affect carbohydrate-deficient transferrin levels. Alcohol Clin Exp Res. 2004;28(9):1347–1355.
Yersin B, Nicolet JF, Decrey H, Burnier M, Van Melle G, Pecoud A. Screening for excessive alcohol drinking. Arch Intern Med. 1995;155:1907–1911.
Bell H, Tallaksen CM, Try K, Haug E. Carbohydrate-deficient transferrin and other markers of high alcohol consumption: a study of 502 patients admitted consecutively to a medical department. Alcohol Clin Exp Res. 1994;18(5):1103–1108.
Conigrave KM, Degenhardt LJ, Whitfield JB, Saunders JB, Helander A, Tabakoff B. CDT, GGT, and AST as markers of alcohol use: the WHO/ISBRA collaborative project. Alcohol Clin Exp Res. 2002;26(3):332–339.
Jatlow P, O’Malley SS. Clinical (nonforensic) application of ethyl glucuronide measurement: are we ready? Alcohol Clin Exp Res. 2010;34(6):968–975.
Kapoor A, Kraemer KL, Smith KJ, Roberts MS, Saitz R. Cost-effectiveness of screening for unhealthy alcohol use with % carbohydrate deficient transferrin: results from a literature-based decision analytic computer model. Alcohol Clin Exp Res. 2009;33(8):1440–1449.
Neumann T, Gentilello LM, Neuner B, et al. Screening trauma patients with the alcohol use disorders identification test and biomarkers of alcohol use. Alcohol Clin Exp Res. 2009;33(6):970–976.
Kristenson H, Ohlin H, Hulten-Nosslin M, Trell E, Hood B. Identification and intervention of heavy drinking in middle-aged men: results and follow-up of 24–60 months of long-term study with randomized controls. Alcohol Clin Exp Res. 1983;7(2):203–209.
Fleming M, Brown R, Brown D. The efficacy of a brief alcohol intervention combined with %CDT feedback in patients being treated for type 2 diabetes and/or hypertension. J Stud Alcohol. 2004;65(5):631–637.
Bradley KA, Williams EC, Achtmeyer CE, Volpp B, Collins BJ, Kivlahan DR. Implementation of evidence-based alcohol screening in the Veterans Health Administration. Am J Manag Care. 2006;12(10):597–606.
Rose HL, Miller PM, Nemeth LS, et al. Alcohol screening and brief counseling in a primary care hypertensive population: a quality improvement intervention. Addiction. 2008;103(8):1271–1280.
Vinson DC, Kruse RL, Seale JP. Simplifying alcohol assessment: two questions to identify alcohol use disorders. Alcohol Clin Exp Res. 2007;31(8):1392–1398.
Rose GL, Skelly JM, Badger GJ, Maclean CD, Malgeri MP, Helzer JE. Automated screening for at-risk drinking in a primary care office using interactive voice response. J Stud Alcohol Drugs. 2010;71(5):734–738.
Rose GL, MacLean CD, Skelly J, Badger GJ, Ferraro TA, Helzer JE. Interactive voice response technology can deliver alcohol screening and brief intervention in primary care. J Gen Intern Med. 2010;25(4):340–344.
Bradley KA, Kivlahan DR, Zhou XH, et al. Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients. Alcohol Clin Exp Res. 2004;28(3):448–455.
Rubinsky AD, Sun H, Blough DK, et al. AUDIT-C alcohol misuse screening results and postoperative inpatient health care utilization. J Am Coll Surg. 2012;214:296–305.e1.
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.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2013 Springer Science+Business Media New York
About this chapter
Cite this chapter
Bradley, K., Berger, D. (2013). Screening for Unhealthy Alcohol Use. In: Saitz, R. (eds) Addressing Unhealthy Alcohol Use in Primary Care. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-4779-5_2
Download citation
DOI: https://doi.org/10.1007/978-1-4614-4779-5_2
Published:
Publisher Name: Springer, New York, NY
Print ISBN: 978-1-4614-4778-8
Online ISBN: 978-1-4614-4779-5
eBook Packages: MedicineMedicine (R0)