A Clinical Guide to Assessing Alcohol Use and Problems
Andrea DiMartini M.D.
University of Pittsburgh Medical Center, Western Psychiatric Institute
Alcohol Medical Scholars Program
A. This Lecture Will Cover (Slide 2)
1. Why alcohol use disorders are important
2. What physicians need to know to appropriately screen
3. Perceived barriers to screening
4. Effective screening techniques
B. Why This Is Important (Slide 3)
b. > 6 % heavy drinkers – defined as 5 drinks 5 or more times in a month
c. Lifetime prevalence of alcohol abuse/dependence 15-20%
b. Assessments are often insufficient to identify problems
c. Alcohol related problems missed more than 50% of the time.
ii. Gastrointestinal (gastritis, stomach/duodenal ulcers)
v. Bone marrow (suppresses marrow – thrombocytopenia / anemia)
c. Biochemical / Nutritional effects:
i. Brain (Wernicke-Korsakoff)
ii. Metabolic acidosis (lactic acidosis / ketoacidosis)
iii. Anemia (B12, folate, iron deficiencies)
d. Alcohol is the third leading cause of preventable death (behind obesity and smoking)
c. May act through changes in lipids (increased HDL) and inhibition of blood clotting (decreased platelet stickiness)
a. No benefit at low levels (i.e. 1-2 drinks)
b. Risk increases dramatically as amount increases
c. Odds of developing cirrhosis increase exponentially above threshold (specific example using alcoholic liver disease)(Slide 8)
i. < 3 drinks/day higher percentage of cirrhosis (0.15) compared to teetotaler (0.04)
ii. > 3 drinks/day dramatically increasing odds (e.g. 10X greater risk of cirrhosis at 3-6 drinks/day compared to teetotaler whose risk is 0)
4. Assess all 3 areas for integrated treatment plan
d. Social/interpersonal problems (e.g. arguments with spouse about drinking, physical fights)
2. Approximately 60% continue with abuse; only 10% go on to develop alcohol dependence
2. Alcohol dependence remains stable over years (unless a patient abstains)
3. Associated with a 10-15 year decrease in lifespan (for above mentioned health reasons), trauma, suicide, etc.
a. Assume your patient would not drink/have a drinking problem
c. Stigma of alcoholism – afraid to offend the patient
e. Afraid to uncover a problem that you won’t know how to handle
f. Forgot to ask -always asking avoids this mistake
a. Afraid that asking alcohol questions will take additional time –however this is like saying you don’t have time to check the blood pressure or ask about medication allergies
b. Afraid to uncover a problem that will require additional time
a. Screening is the first step in a process toward further evaluation
b. Primary objective is to detect individuals with alcohol problems
c. Screening should facilitate further assessment or subsequent referral for assessment in those who screen positive
c. Determines alcohol use disorders diagnosis
a. Abuse/dependence diagnoses depend on the pattern of the problems
b. May be easier to engage patient in discussion about problems
a. May be difficult to get accurate information on quantity/frequency
b. Important in assessing health risks
1. Physical exam - supplements data from interview, can identify physical problems that can be used to corroborate or augment discussion of reported use
3. Interview - primary method to gather information on all domains of alcohol problems
4. May be perceived as easier method to gather data
a. Increased GGTP related to enzyme induction (initially) or liver cell death (chronic use). May be initially increased before changes in MCV (see below).
b. GGTP can begin to normalize in 1-2 weeks with abstinence
c. Even normal GGTP values (i.e. higher than 35 IU/L) may indicate heavy alcohol use (i.e. > 6 drinks) - normal healthy people do not usually have such values
e. For the general population average sensitivity of GGTP in detecting heavy alcohol use is 40-60%, specificity is 90% (except for medically ill populations)
f. Increase of GGTP by 20% over baseline was 100% sensitive and 80% specific detecting alcohol relapse after rehabilitation
a. Alcohol and its metabolic derivative acetaldehyde exert toxic effects on the nuclear maturation of red blood cells
b. Can be associated with coincident folic acid or B12 deficiency which also cause macrocytosis
c. MCV > 98 femtoliters (fL) (or cubic micrometers - mm3 ) reflects macrocytosis
d. MCV > 98 fL has been reported in up to a third of heavy drinkers, but also in 5% normal drinkers
f. For the general population average sensitivity of MCV in detecting heavy alcohol use is 30-40% and specificity is 90%
c. For alcohol use >6 drinks/day CDT sensitivity is 60-80% and specificity is 80-90%
d. Limit of detection <0.01 g/dl
e. In comparison the legal limit, depending on the state, is 0.08-0.10 g/dl
f. For example, on average Ĺ of a standard drink can raise the BAL by 0.02 g/dl in an individual.
a. Mild elevation in blood pressure (drinking > 3 drinks/day is an important contributor to mild to moderate hypertension)
b. Irregular heart rhythms or tachycardia
e. Other rarer features
i. Skin - spider angiomata, palmar erythema, Dupytren's contracture
ii. Gynecomastia (men)
iii. Parotid gland swelling
a. A substantial proportion of alcoholics never go into withdrawal. In normal healthy persons clinically observable withdrawal is uncommon. It is more likely to occur in medical / surgical patients.
i. If withdrawal is present must think of alcohol dependence
ii. However, lack of withdrawal symptoms does not mean absence of alcohol dependence
b. 95% of withdrawals limited to mild or moderate symptoms (listed below)
c. Only 5-10% alcohol dependent individuals ever experience delirium tremens (DTs)
h. Anxiety, irritability, restlessness, agitation
3. Doctor can score/review with patient during interview
4. Questionnaires available that assess patterns / problems of use
H. Specific Questionnaires (Slide 25)
1. These questionnaires can be completed in 10 minutes or less
2. Scored by physician/clinician 5 minutes or less
i. 4 items Cut down, Annoyed, Guilt, Eye-opener
ii. Self-administered or interview
iii. Less than one minute
iv. “Yes” response on one or more questions may indicate alcohol-related problems
v. One or more positive response - 60-70% sensitivity for identifying alcohol abuse/dependence and specificity of 80%.
i. 25 items (there is also a 10 item version)
ii. Self-administered or interview
iii. 10 minutes to complete
iv. 5 minutes to score
v. Identifies alcohol use problems
i. 10 items
ii. Self-administered or interview
iii. 2 minutes to complete
iv. 1 minute to score
v. Includes questions on quantity/frequency and alcohol use problems
vi. Originally developed as screening instrument for primary care settings
vii. Specifically designed to identify hazardous and harmful drinking
a. Engage in dialogue (avoid rapid firing of questions)
b. Non-judgmental approach
c. Can use questionnaire responses
d. Avoid close-ended questions (e.g. Do you drink alcohol?)
A. Alcohol Frequently Impacts Health And Heath Care Delivery
B. Knowing Of Barriers To Screening Will Prevent Barriers From Becoming An Obstacles
C. Assess For Problems
1. Alcohol use problems are diagnosed by problems associated with alcohol use
2. Health problems are associated with patterns of use
3. Assessing both areas provides a more comprehensive picture of potential risks
D. Utilize Effective Screening Techniques Described In This Lecture
Allen JP, Reinert DF, Volk RJ. The alcohol use disorders identification test: an aid to recognition of alcohol problems in primary care patients. Preventive Medicine. 33:428-33, 2001.
Andréasson S, Hjalmarsson K, Rehnman C. Implementation and dissemination of methods for prevention of alcohol problems in primary health care: a feasibility study. Alcohol and Alcoholism 35: 525-530, 2000.
Anton, R.F., Litten, R.Z., Allen, J.P. Biological assessment of alcohol consumption. In: Allen, J.P., Columbus, M. (Eds.), Assessing Alcohol Problems: A Guide for Clinicians and Researchers, National Institute on Alcohol Abuse and Alcoholism, pp. 31-41, NIAAA NIH publication No. 95-3745, 1995.
Bellentani S. Tiribelli C. The spectrum of liver disease in the general population: lesson from the Dionysos study. Journal of Hepatology. 35:531-7, 2001.
Connors, G. Screening for alcohol problems. In: Allen, J.P., Columbus, M. (Eds.), Assessing Alcohol Problems: A Guide for Clinicians and Researchers, National Institute on Alcohol Abuse and Alcoholism, pp. 17-29, NIAAA NIH publication No. 95-3745, 1995.
Gerbert, B. G., Bronstone, A., Pantilat, S., McPhee, S., Allerton, M., & Moe, J. When asked, patients tell: Disclosure of sensitive health-risk behaviors. Medical Care. 37: 104-111, 1999.
Klatsky A. Should patients with heart disease drink alcohol? JAMA 285: 2004-2006, 2001.
Maisto S, Saitz R. Alcohol Use Disorders: Screening and Diagnosis. Am. J. Addictions. 12: S12-S25, 2003.
McCusker MT. Basquille J. Khwaja M. Murray-Lyon IM. Catalan J. Hazardous and harmful drinking: a comparison of the AUDIT and CAGE screening questionnaires. Qjm. 95:591-5,2002.
Rehm J. Room R. Graham K. Monteiro M. Gmel G. Sempos CT. The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. Addiction. 98:1209-28, 2003.
Reid, M.C., Fiellin, D. A., & O'Connor, P.G. Hazardous and harmful alcohol consumption in primary care. Archives of Internal Medicine. 159: 1681-1689, 1999.
Schuckit M. Alcohol and Alcoholism. Chapter 387 in Harrison's Principles of Internal Medicine 15th edition, Braunwald, Fauci, Kasper, Hauser, Longo, Jameson (editors), McGraw-Hill 2001.
Stein, M. D. Medical consequences of substance abuse. The Psychiatric Clinics of North America. 22: 351-370, 1999.
Thun MJ. Peto R. Lopez AD. Monaco JH. Henley SJ. Heath CW Jr. Doll R. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. New England Journal of Medicine. 337:1705-14, 1997.
The materials below can be ordered from the NIAAA Publications Distribution Center, P.O. Box 10686, Rockville, MD 20849-0686; phone: (301) 443-3860. They are also available in full text on NIAAA's Web site (www.niaaa.nih.gov). NIAAA continually develops and updates materials for practitioners and patients; please check the Web site for new offerings.
Alcohol and Disease Interaction Vol.25, No. 4, 2001.
What Is Moderate Drinking? Vol. 23, No. 1, 1999
Alcohol's Effect on Organ Function Vol, 21, No. 1, 1997
Alcohol: A Women's Health Issue--Describes the effects of alcohol on women's health at different stages in their lives. NIH Publication No. 02-5152. Also available: a 12-minute video, with the same title, that describes the health consequences of heavy drinking in women.
Alcohol: What You Don't Know Can Harm You--Provides information on drinking and driving, alcohol-medication interactions, interpersonal problems, alcohol-related birth defects, long-term health problems, and current research issues. English version: NIH Publication No. 99-4323; Spanish version: NIH Publication No. 99-4323-S.
Alcoholism: Getting the Facts--Describes alcoholism and alcohol abuse and offers useful information on when and where to seek help. English version: NIH Publication No. 96-4153; Spanish version: NIH Publication No. 99-4153-S.
Drinking and Your Pregnancy--Briefly conveys the lifelong medical and behavioral problems associated with fetal alcohol syndrome and advises women not to drink during pregnancy. Revised 2001. English version: NIH Publication No. 96-4101; Spanish version: NIH Publication No. 97-4102.
Frequently Asked Questions About Alcoholism and Alcohol Abuse--English version: NIH Publication No. 01-4735; Spanish version: NIH Publication No. 02-4735-S.
Rethinking Drinking--Provides patients with a self-evaluation and tips for cutting down on drinking. Scheduled for publication in English and Spanish in 2003.
Copy of the Alcohol Use Disorders Identification Test (AUDIT)
Copyright permission for use of the AUDIT:
The following quotation from the AUDIT User’s manual (Babor et al. 2002) describes the fact that the copyright is held by WHO but permission to use the test does not have to be obtained when it is being used for noncommercial purposes. “This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced, and translated, in part or in whole but not for sale or for use in conjunction with commercial purposes. Inquiries should be addressed to the Department of Mental Health and Substance Dependence, World Health Organization, CH-1211 Geneva 27, Switzerland, which will be glad to provide the latest information on any changes made to the text, plans for new editions and the reprints, regional adaptations and translations that are already available.”
Procedure For Scoring AUDIT
Questions 1-8 are scored 0, 1, 2, 3 or 4.
Questions 9 and 10 are scored 0, 2 or 4 only. The response is as follows:
Question 1 Never Monthly Two to Two to Four or more
or less four times three times times per week per month per week
Question 2 1 or 2 3 or 4 5 or 6 7 or 9 10 or more
Question 3-8 Never Less than Monthly Weekly Daily or
Monthly almost daily
Question 9-10 No Yes, but Yes, during
not in the the last year
The minimum score (for non-drinkers) is 0 and the maximum possible score is 40.
A score of 8 or more indicates a strong likelihood of hazardous or harmful alcohol consumption.
9. Have you or has someone else been injured as a result of your drinking?
No Yes, but not in the past year Yes, during the past year
10. Has a relative of friend or a doctor or other health worker been concerned about your drinking or suggested that you cut down?
No Yes, but not in the past year Yes, during the past year