Excessive alcohol use adversely affects an estimated 38 million (30%) adults in the United States, but surprisingly, only 1 out 6 say they talk to their doctor, nurse, or healthcare professional about drinking (1). More than 30 years of research has shown the impact that alcohol screening and brief counseling have—they can reduce the quantity of alcohol consumed on one occasion by 25% (2). Besides any alcohol consumption by individuals under the age of 21 or by pregnant women, unsafe drinking is defined as drinking five drinks per event for men or four drinks for per event for women (3).
Similar to how blood pressure or breast cancer screening save lives, alcohol screenings also can reduce the number of adults who are negatively impacted by risky drinking habits. The Centers for Disease Control and Prevention (CDC) reported earlier this year that drinking too much claims about 88,000 lives each year and costs the economy $224 billion in 2006 (4,5). The health and social repercussions of high-risk alcohol consumption are valid public concerns, particularly to the medical community who are in a position to discourage this unhealthy behavior.
Together we as physicians can proactively work towards lessening problem drinking by utilizing effective and validated questionnaires in our daily medical practices. We then can identify signs of developing substance use disorders (SUD) before the patient develops overt alcoholism or drug dependence.
Two Straightforward Alcohol Screening Tools to Help Physicians Discover a Fuller Spectrum of Problem Drinking
As we strive to care for the maximum number of patients in our allotted schedules, it may seem like a daunting task to add another requirement to our day. But screening patients for alcohol misuse doesn’t have to take a lot of time. Physicians can add a set of questions to patient history forms, via paper or electronic health records, to ask how much and how often all patients drink. Furthermore, physicians do not have to administer the questionnaire personally; it can be provided by nurses, medical assistants, social workers, and psychologists while maintaining its statistical validity (6).
1. The CAGE Questionnaire
I’d recommend any physician, who is new to screening for the warning signs of a developing SUD, begin using the CAGE questionnaire. John Ewing, MD, the Director of the Bowles Center for Alcohol Studies at the University of North Carolina at Chapel Hill, deserves credit for developing this tool. The CAGE is a brief, four-question survey that can quickly identify when a high risk alcohol problem is present. CAGE is an acronym, where each letter coincides with the most significant word in that question; so one can recall the word C-A-G-E as a memory aid to remember to ask:
♦ Have you ever felt you should Cut down on your drinking?
♦ Have people Annoyed you by criticizing your drinking?
♦ Have you ever felt bad or Guilty about your drinking?
♦ Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?
Each question is answered ‘Yes’ or ‘No.’ One ‘Yes’ is presumed to be within the range of normal drinking. Two or more affirmative answers strongly suggest an unhealthy drinking habit (7). These patients need immediate referral to an addiction specialist for further diagnostic evaluation and management. You can access the full CAGE questionnaire here.
On the other hand, if you are performing routine screenings of all patients for alcohol abuse using the CAGE, congratulations—my hat is off to you! Nice job! Now I would challenge you to go one step further and begin integrating the Alcohol Use Disorders Identification Test (AUDIT) into your practice.
2. The AUDIT Questionnaire
Developed by the World Health Organization, this multiple-choice questionnaire employs 10 questions to recognize a fuller spectrum of alcohol use ranging from:
- risky use, to
- problem drinking, to
- alcohol abuse or harmful use, all the way up to
- true alcohol dependence, or alcoholism (8)
Researchers have found the AUDIT is over 90% sensitive across all gender and ethnic groups. Like the CAGE, this questionnaire is also scored on a point system. The first eight questions have five possible responses, and the last two questions have three possible answers. Each possible response carries a number score with it, and at the end of the questionnaire, all the numbers are summed and then totaled.
For illustrative purposes, I’m listing the 10 questions here, so you can compare them to the four CAGE questions above. But to fully comprehend the power of the AUDIT, you will want to read the possible answers to each question. You can access the complete AUDIT screening tool here.
(It should be noted for the purpose of this screening test, a drink is defined as follows: 1) a single small glass of beer (8 ounces; 1/2 pint), 2) a single shot or measure of liquor/spirits, 3) a single glass of wine.)
1) How often do you have a drink containing alcohol?
2) How many drinks containing alcohol do you have on a typical day when you are drinking? (definition of a drink listed above)
3) How often do you have 6 or more drinks on one occasion?
4) How often during the last year have you found that you were not able to stop drinking once you had started?
5) How often during the last year have you failed to do what was normally expected from you because of drinking?
6) How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
7) How often during the last year have you had a feeling of guilt or remorse after drinking?
8) How often during the last year have you been unable to remember what happened the night before because you had been drinking?
9) Have you or someone else been injured as a result of your drinking?
10) Has a relative, friend, doctor, or another health professional expressed concern about your drinking or suggested you cut down?
Once the responses to the questionnaire have been collected, a brief counseling session of 6-15 minutes is recommended to counsel the patient about the health dangers of drinking too much. The WHO advises, “Scores between 8 and 15 are most appropriate for simple advice focused on the reduction of hazardous drinking. Scores between 16 and 19 suggest brief counseling and continued monitoring. Scores of 20 or above clearly warrant further diagnostic evaluation for alcohol dependence” (9), which may indicate the need for referral to an addictionologist. Of course, follow-up PCP appointments are necessary to track and monitor the patient’s progression towards achieving long-term sobriety.
What Every Physician Can Do to Mitigate Problem Drinking
Physicians and all healthcare professionals should consider taking three essential steps toward reducing the number of patients over-consuming alcohol:
♦ Screen all adult patients for alcohol use as part of your regular intake services, including those who are younger than the legal drinking age and women who are or may be pregnant.
♦ Recruit and train a staff of nurses, social workers, and health educators to assist in screening and counseling patients. The NIAAA Clinician’s Guide for helping patients with alcohol problems is a great resource to aid you in learning effective alcohol screening and counseling techniques (10).
♦ Offer patients electronic screening and brief intervention (e-SBI) tools that can be accessed via computers, telephones, or mobile devices at any time or any place. At minimum these screening instruments are helpful in warning patients about the dangers of drinking too much. Brief interventions delivered by an automated system or by a person over the telephone may also provide personalized feedback about the risks and consequences of excessive drinking (11).
Alcohol screening and brief interventions have a positive impact on the lives of adults who frequently drink to excess, as thus benefit society and the medical community at large. My next post will discuss the e-SBI tools I just mentioned, to explain how they work and present a suggested plan for you to begin using them to help your recovering patients.
Robb Hicks, MD, is a Certified Physician Development Coach and the Founder and President of two companies. HEAL Your Career is a professional career consulting and life fulfillment coaching firm, and Intentional Sobriety helps recovering professionals stop relapsing, so they stay sober forever, face life successfully, and become happy, joyous & free. To learn more about what coaching is, and the power coaching creates in industry worldwide, please click here.
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Readings & Resources (click to view)
1) The Centers for Disease Control and Prevention. (2014, January). Alcohol screening and counseling. Vital Signs. Available at: http://www.cdc.gov/vitalsigns/alcohol-screening-counseling/index.html
3) Alcohol Alert. (2005, April). National Institute on Alcohol Abuse and Alcoholism. Available at: http://pubs.niaaa.nih.gov/publications/aa65/AA65.htm
5) Bouchery EE, Harwood HJ, Sacks JJ, Simon CJ, Brewer RD. (2011). Economic costs of excessive alcohol consumption in the U.S., 2006. American Journal of Preventive Medicine, 41(5):516-24.
6) Frieden, MD, T. (2014). Too much Alcohol: Making screening and counseling routine. Medscape. Available at: http://www.medscape.com/viewarticle/818635#2
7) Ewing, J.A. (1984). Detecting alcoholism: The CAGE questionnaire. JAMA: Journal of the American Medical Association, 252, pp. 1905–1907.
8) Saunders JB, Aasland OG, Babor TF et al. (1993). Development of the alcohol use disorders identification test(AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption. Addiction. 88: pp. 791–803.
9) Babor, T., Higgins-Biddle, J. Saunders, J., Monteiro, M. (2001). The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care (Second Edition). World Health Organization.
10) Helping patients who drink too much: A clinician’s guide. (2005). National Institute on Alcohol Abuse and Alcoholism. Available at: http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm
11) Preventing excessive alcohol consumption: Electronic screening and brief intervention (e-SBI). (2014). The Guide to Community Preventive Services. Available at http://www.thecommunityguide.org/alcohol/eSBI.html