Alcohol Screening and Brief Interventions
Drinking Levels and Advice
Diagnosing and Helping Patients with Alcohol Use Disorders
alcohol screening and brief interventions
effective is screening for heavy drinking?
Studies have demonstrated
that screening is sensitive and that patients are willing to give honest information
about their drinking to health care practitioners when appropriate methods are
Several methods have been shown to work, including quantity-frequency interview
questions and questionnaires such as the CAGE, the AUDIT, the shorter AUDIT-C,
the TWEAK (for pregnant women), and others.28,29
In this Guide, the single screening question about heavy drinking days
was chosen for its simplicity and because almost all people with alcohol use disorders
report drinking 5 or more drinks in a day (for men) or 4 or more (for women) at
least occasionally. This Guide also recommends the AUDIT (provided on
page 11) as a self-administered screening tool because of its high levels of validity
the single interview question, screening is positive with just one heavy drinking
day in the past year. Isn’t that casting a very broad net?
common reaction to the screening question is, “Everybody’s going to
meet this, at least occasionally.” A large national survey by NIAAA, however,
showed that nearly three-fourths of U.S. adults never exceed the limits in the
Even if patients report that they only drink heavily on rare occasions, screening
provides an opportunity to educate them about safe drinking limits so that heavy
drinking doesn’t become more frequent. The risk for alcohol-related problems
rises with the number of heavy drinking days,1
and some problems, such as driving while intoxicated or trauma, can occur with
a single occasion.
effective are brief interventions?
Randomized, controlled clinical
trials in a variety of populations and settings have shown that brief interventions
can decrease alcohol use significantly among people who drink above the recommended
limits but aren’t dependent. In several intervention trials with multiple
brief contacts, for example, heavy drinkers cut an average of three to nine drinks
per week, for a 13 to 34 percent net reduction in consumption.30
Even relatively modest reductions in drinking can have important health benefits
when spread across a large number of people. Brief intervention trials have also
reported significant decreases in blood pressure readings, levels of gamma-glutamyl
transferase (GGT), psychosocial problems, hospital days, and hospital readmissions
for alcohol-related trauma.8
Followup periods typically range from 6 to 24 months, although one recent study
reported sustained reductions in alcohol use over 48 months.8
A cost-benefit analysis in this study showed that each dollar invested in brief
physician intervention could reap more than fourfold savings in future health
care costs. Other research shows that for alcohol dependent patients with an alcohol-related
medical illness, repeated brief interventions at approximately monthly intervals
for 1 to 2 years can lead to significant reductions in or cessation of drinking.9,10
- What can I
do to encourage my patients to give honest and accurate answers to the screening
It’s often best to ask about alcohol consumption
at the same time as other health behaviors such as smoking, diet, and exercise.
Using an empathic, nonconfrontational approach can help put patients at ease.
Some clinicians have found that prefacing the alcohol questions with a nonthreatening
opener such as “Do you enjoy a drink now and then?” can encourage
reserved patients to talk. Patients may feel that a written or computerized self-report
version of the AUDIT is less confrontational as well. To improve the accuracy
of estimated drinking quantities, you could ask patients to look at the “What’s
a Standard Drink?” chart. Many people are surprised to learn what counts
as a single standard drink, especially for beverages with a higher alcohol content
such as malt liquors, fortified wines, and spirits. The chart also lists the number
of standard drinks in commonly purchased beverage containers. In some situations,
you may consider adding the questions “How often do you buy alcohol?”
and “How much do you buy?” to help build an accurate estimate.
- How can
a clinic- or office-based screening system be implemented?
studied method, which is both easy and efficient, is to ask patients to fill out
the 10-item AUDIT before seeing the doctor. This form (provided on page 11) can
be added to others that patients fill out. The full AUDIT or the 3-item AUDIT-C
can also be incorporated into a larger health history form. The AUDIT-C consists
of the first three consumption-related items of the AUDIT; a score of 6 or more
for men and 4 or more for women 31
indicates a positive screen. Alternatively, the single-item screen in Step 1 of
this Guide could be incorporated into a health history form. Screening
can also be done in person by a nurse during patient check-in. (See also “Set
Up Your Practice to Simplify the Process” on page 3.)
Are there any specific considerations for implementing screening in mental health
Studies have demonstrated a strong relationship between
alcohol use disorders and other mental disorders.32
Heavy drinking can cause psychiatric symptoms such as depression, anxiety, insomnia,
cognitive dysfunction, and interpersonal conflict. For patients who have an independent
psychiatric disorder, heavy drinking may compromise the treatment response. Thus,
it is important that all mental health clinicians conduct routine screening for
heavy drinking. Less is known about the performance of screening methods or brief
interventions in mental health settings than in primary care settings. Still,
the single-question screener in this Guide is likely to work reasonably
well, since almost everyone with an alcohol use disorder reports drinking above
the recommended daily limits at least occasionally. Mental health clinicians may
need to conduct a more thorough assessment to determine whether an alcohol use
disorder is present and how it might be interacting with other mental or substance
use disorders. The recommended limits for drinking may need to be lowered depending
on coexisting problems and prescribed medications. Similarly, a more extended
behavioral intervention may be needed to address coexisting alcohol use disorders,
either delivered as part of mental health treatment or through referral to an
drinking levels and advice
- When should I recommend
abstaining versus cutting down?
Certain conditions warrant advice
to abstain as opposed to cutting down. These include when drinkers:
patients with alcohol use disorders are unwilling to commit to abstinence, they
may be willing to cut down on their drinking. This should be encouraged while
noting that abstinence, the safest strategy, has a greater chance of long-term
- are or may become pregnant,
taking a contraindicated medication (see box, below),
a medical or psychiatric disorder caused or exacerbated by drinking, or
have an alcohol use disorder.
For heavy drinkers who do not have an alcohol use disorder,
use professional judgment to determine whether cutting down or abstaining is more
appropriate, based on factors such as these:
family history of alcohol problems
- injuries related
such as sleep disorders or sexual dysfunction
It may be useful to discuss different options, such as cutting down to recommended
limits or abstaining completely for perhaps a month or two, then reconsidering
future drinking. If cutting down is the initial strategy but the patient is unable
to stay within limits, recommend abstinence.
Interactions Between Alcohol and Medications|
can interact negatively with medications either by interfering with the metabolism
of the medication (generally in the liver) or by enhancing the effects of the
medication (particularly in the central nervous system). Many classes of prescription
medicines can interact with alcohol, including antibiotics, antidepressants, antihistamines,
barbiturates, benzodiazepines, histamine H2 receptor agonists, muscle relaxants,
nonopioid pain medications and anti-inflammatory agents, opioids, and warfarin.
In addition, many over-the-counter medications and herbal preparations can cause
negative side effects when taken with alcohol.
- How do I factor
the potential benefits of moderate drinking into my advice to patients who drink
rarely or not at all?
Moderate consumption of alcohol (defined by
U.S. Dietary Guidelines as up to two drinks a day for men and one for women) has
been associated with a reduced risk of coronary heart disease.33
Achieving a balance between the risks and benefits of alcohol consumption remains
difficult, however, because each person has a different susceptibility to diseases
potentially caused or prevented by alcohol. The advice you would give to a young
person with a family history of alcoholism, for example, would differ from the
advice you would give to a middle-aged patient with a family history of premature
heart disease. Most experts don’t recommend advising nondrinking patients
to begin drinking to reduce their cardiovascular risk. However, if a patient is
considering this, discuss safe drinking limits and ways to avoid alcohol-induced
Why are the recommended drinking limits lower for some patients?
limits are lower for women because they have proportionally less body water than
men do and thus achieve higher blood alcohol concentrations after drinking the
same amount of alcohol. Older adults also have less lean body mass and greater
sensitivity to alcohol’s effects. In addition, there are many clinical situations
where abstinence or lower limits are indicated because of a greater risk of harm
associated with drinking. Examples include women who are or may become pregnant,
patients taking medications that may interact with alcohol, young people with
a family history of alcohol dependence, and patients with physical or psychiatric
conditions that are caused by or exacerbated by alcohol.
Some of my patients who drink heavily believe that this is normal. What percentage
of people drink at, above, or below moderate levels?
About 7 in
10 adults abstain, drink rarely, or drink within the daily and weekly limits noted
in Step 1.3
The rest exceed the daily limits, the weekly limits, or both. The “U.S.
Adult Drinking Patterns” chart on page 25 shows the percentage of drinkers
in each category, as well as the prevalence of alcohol use disorders in each group.
Because heavy drinkers often believe that most people drink as much and as often
as they do, providing normative data about U.S. drinking patterns and related
risks can provide a helpful reality check. In particular, those who believe that
it’s fine to drink moderately during the week and heavily on the weekends
need to know that they have a higher chance not only of immediate alcohol-related
injuries, but also of developing alcohol use disorders and other alcohol-related
medical and psychiatric disorders.
of my patients who are pregnant don’t see any harm in having an occasional
drink. What’s the latest advice?
Some pregnant women may not
be aware of the risks involved with drinking, while others may drink before they
realize they’re pregnant. A recent survey estimates that 1 in 10 pregnant
women in the United States drinks alcohol.34
In addition, among sexually active women who aren’t using birth control,
more than half drink and 12.4 percent report binge drinking, placing them at particularly
high risk for an alcohol-exposed pregnancy.34
Each year, an estimated 2,000 to 8,000 infants are born with fetal alcohol
syndrome in the United States, and many thousands more are born with some degree
of alcohol-related effects.35
These problems range from mild learning and behavioral problems to growth deficiencies
to severe mental and physical impairment. Together, these adverse effects comprise
fetal alcohol spectrum disorders.
Because it isn’t known whether
any amount of alcohol is safe during pregnancy, the Surgeon General recently reissued
an advisory that urges women who are or may become pregnant to abstain from drinking
The advisory also recommends that pregnant women who have already consumed alcohol
stop to minimize further risks and that health care professionals inquire routinely
about alcohol consumption by women of childbearing age.
diagnosing and helping patients with alcohol use disorders
- What if a patient reports
some symptoms of an alcohol use disorder but not enough to qualify for a diagnosis?
Alcohol use disorders are similar to other medical disorders such as
hypertension, diabetes, or depression in having “gray zones” of diagnosis.
For example, a patient might report a single arrest for driving while intoxicated
and no other symptoms. Since a diagnosis of alcohol abuse requires repetitive
problems, that diagnosis couldn’t be made. Similarly, a patient might report
one or two symptoms of alcohol dependence, but three are needed to qualify for
Any symptom of abuse or dependence is a cause for concern
and should be addressed, since an alcohol use disorder may be present or developing.
These patients may be more successful with abstaining as opposed to cutting down
to recommended limits. Closer followup is indicated, as well as reconsidering
the diagnosis as more information becomes available.
Should I recommend any particular behavioral therapy for patients with alcohol
Several types of behavioral therapy are used to treat
alcohol use disorders. Cognitive-behavioral therapy, motivational enhancement,
and 12-step facilitation (e.g., the Minnesota Model) have all been shown to be
A combination of approaches has been shown to be effective as well (see the next
question). Getting help in itself appears to be more important than the particular
approach used, provided it avoids heavy confrontation and incorporates the basic
elements of empathy, motivational support, and an explicit focus on changing drinking
behavior. For patients receiving medications for alcohol dependence, brief medical
counseling sessions delivered by a nurse or physician have been shown to be effective
without additional behavioral treatment by a specialist22
(see page 17).
In addition to more formal treatment approaches, mutual
help groups such as Alcoholics Anonymous (AA) appear to be very beneficial for
people who stick with them. AA is widely available, free, and requires no commitment
other than a desire to stop drinking. If you’ve never attended a meeting,
consider doing so as an observer and supporter. To learn more, visit www.aa.org.
Other self-help organizations that offer secular approaches, groups for women
only, or support for family members can be found on the National Clearinghouse
for Alcohol and Drug Information Web site (www.ncadi.samhsa.gov)
a mental health clinician, how can I learn more about specialized alcohol counseling?
For a recent major clinical trial, NIAAA grantees designed state-of-the-art
individual outpatient psychotherapy for alcohol dependence. Called a combined
behavioral intervention (CBI), it integrates cognitive-behavioral therapy, motivational
enhancement, 12-step approaches, couples therapy, and community reinforcement—all
treatments shown in earlier studies to be beneficial. Behavioral specialists deliver
CBI in up to 20 sessions of 50 minutes (the median in the trial was 10 sessions).
The treatment has four phases: building motivation for change, developing an individual
plan for treatment and change, completing individualized skill-training modules,
and performing maintenance checkups. Findings from the trial show that this specialized
alcohol counseling or the medication naltrexone was effective, when coupled with
structured medical management.22
The CBI strategy and supporting materials are provided in the 328-page Combined
Behavioral Intervention Manual from Project COMBINE; to order for a small
fee, visit www.niaaa.nih.gov/guide.
should alcohol withdrawal be managed?
Alcohol withdrawal results
when a person who is alcohol dependent suddenly stops drinking. Symptoms usually
start within a few hours and consist of tremors, sweating, elevated pulse and
blood pressure, nausea, insomnia, and anxiety. Generalized seizures may also occur.
A second syndrome, alcohol withdrawal delirium, sometimes follows. Beginning after
1 to 3 days and lasting 2 to 10 days, it consists of an altered sensorium, disorientation,
poor short-term memory, altered sleep-wake cycle, and hallucinations. Management
typically consists of administering thiamine and benzodiazepines, sometimes together
with anticonvulsants, beta adrenergic blockers, or antipsychotics as indicated.
Mild withdrawal can be managed successfully in the outpatient setting, but more
complicated or severe cases require hospitalization. (Consult references 37 and
38 on page 34 for additional information.)
laboratory tests available to screen for or monitor alcohol problems?
screening purposes in primary care settings, interviews and questionnaires have
greater sensitivity and specificity than blood tests for biochemical markers,
which identify only about 10 to 30 percent of heavy drinkers.39,40
Nevertheless, biochemical markers may be useful when heavy drinking is suspected
but the patient denies it. The most sensitive and widely available test for this
purpose is the serum gamma-glutamyl transferase (GGT) assay. It isn’t very
specific, however, so reasons for GGT elevation other than excessive alcohol use
need to be eliminated. If elevated at baseline, GGT and other transaminases may
also be helpful in monitoring progress and identifying relapse, and serial values
can provide valuable feedback to patients after an intervention. Other blood tests
include the mean corpuscular volume (MCV) of red blood cells, which is often elevated
in people with alcohol dependence, and the carbohydrate-deficient transferrin
(CDT) assay. The CDT assay is about as sensitive as the GGT and has the advantage
of not being affected by liver disease.41
I refer a patient for alcohol treatment, what are the chances for recovery?
A review of seven large studies of alcoholism treatment found that about
one-third of patients either were abstinent or drank moderately without negative
consequences or dependence in the year following treatment.42
Although the other two-thirds had some periods of heavy drinking, on average they
reduced consumption and alcohol-related problems by more than half. These reductions
appear to last at least 3 years.36
This substantial improvement in patients who do not attain complete abstinence
or problem-free reduced drinking is often overlooked. These patients may require
further treatment, and their chances of benefiting the next time don’t appear
to be influenced significantly by having had prior treatments.42
As is true for other medical disorders, some patients have more severe forms of
alcohol dependence that may require long-term management.
What can I do to help patients who struggle to remain abstinent or who relapse?
Changing drinking behavior is a challenge, especially for those who are
alcohol dependent. The first 12 months of abstinence are especially difficult,
and relapse is most common during this time. If patients do relapse, recognize
that they have a chronic disorder that requires continuing care, just like asthma,
hypertension, or diabetes. Recurrence of symptoms is common and similar across
each of these disorders,43
perhaps because they require the patient to change health behaviors to maintain
gains. The most important principle is to stay engaged with the patient and to
maintain optimism about eventual improvement. Most people with alcohol dependence
who continue to work at recovery eventually achieve partial to full remission
of symptoms, and often do so without specialized behavioral treatment.44
For patients who struggle to abstain or who relapse:
- If the patient is not taking medication
for alcohol dependence, consider prescribing one and following up with medication
management (see pages 13-22).
depression or anxiety disorders if they are present more than 2 to 4 weeks after
abstinence is established.
and address other possible triggers for struggle or relapse, including stressful
events, interpersonal conflict, insomnia, chronic pain, craving, or high-temptation
situations such as a wedding or convention.
the patient is not attending a mutual help group or is not receiving behavioral
therapy, consider recommending these support measures.
those who have relapsed by noting that relapse is common and pointing out the
value of the recovery that was achieved.
Provide followup care and advise patients to contact you if they are concerned
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