Screening for alcohol problems is important in social work practice for many reasons:
- As outlined in Modules 1 and 2, a large number and wide range of physical, mental health, family, social, and work problems result from alcohol abuse and dependence.
- Whether or not a causal relationship exists between alcohol use and other social work problems such as child maltreatment, intimate partner violence, economic and social vulnerability, it is clear that significant associations with alcohol problems do exist.
- It is important to recognize that the effectiveness of social workers' efforts to help clients solve various types of alcohol-related problems will suffer unless and until alcohol use concerns are sufficiently addressed.
Social workers encounter individuals with alcohol use problems in every setting, not only in settings specifically designed to treat and prevent alcohol problems. Thus, it is necessary for all social work professionals, at a minimum, to be able to identify individuals who would benefit from referral to specialized services for alcohol treatment. In addition, it is important for social workers to identify those individuals who do not necessarily meet the criteria for abuse or dependence, yet are drinking at levels that place them at risk for problems. Not only will this enhance effectiveness in working with the target problems, it is important to implement effective interventions for alcohol abuse prevention. In short, social workers in many different settings can improve outcomes for their clients by becoming skilled in identifying alcohol problems and intervening in appropriate ways.
This module presents current "best practices" for the screening of individuals for both at-risk and dependent alcohol use in general social work practice settings. Methods for conducting more in-depth assessment and diagnosis in the context of addiction treatment programs are provided in later modules.
By the end of this module, learners should be able to:
A. Understand the concepts of sensitivity and specificity in reference to acceptable screening approaches.
B. Recognize a number of empirically-based screening methods and approaches for the detection of alcohol and drug problems.
C. Select specific empirically-supported screening methods for implementation into their own practices.
Usefulness of Current Screening Tests
Screening for alcohol-related problems usually involves asking patients questions about their drinking practices. This typically occurs through either structured interviews or self-report questionnaires. Alcohol screening instruments that have been tested and validated in clinical settings include brief, structured interviews with questions on how much and how often a person drinks; questionnaires that are self-administered or used in an interview by a trained professional; and clinical laboratory tests. Medical laboratory tests to detect abnormalities associated with excessive alcohol use are available, but limited in their usefulness. Therefore, they will be discussed only briefly. When an alcohol problem is identified through initial screening, a more detailed alcohol-specific diagnostic assessment is necessary to specify the nature and extent of the problem and to determine the next best steps for the client.
Research that supports the efficacy of the screening methods presented here comes primarily from medical and other clinical settings. Additional research is needed concerning their effectiveness when delivered by social workers practicing in traditional social work settings. The appendix to this module includes copies of the most often-used screening instruments.
The accuracy of screening tests is determined by their sensitivity and specificity. These characteristics of a screening test are documented through research studies. Sensitivity is a measure of the instrument's accuracy in detecting individuals who do experience an alcohol problem. An alcohol screening instrument with high sensitivity very rarely gives a "false negative" result. This means that the instrument does not tend to fail us by indicating that someone has no problem when, in fact, the person actually does (for example, an HIV positive individual who has a "clean" test result).
Specificity, on the other hand, is a measure of how well the tool accurately identifies people who truly do not have an alcohol problem. An alcohol screening instrument with high specificity very rarely gives "false positive" results. This means that the instrument does not result in inappropriately labeling a person as having a problem when a problem does not actually exist (for example, a breast cancer diagnosis based on a mammogram that detects what is actually a benign cyst).
Sensitivity and specificity are important in screening because this is what allows social workers to accurately and appropriately direct resources where they are most needed and not waste effort where intervention is not required. This is also what helps social workers avoid having needy clients "fall through the cracks" undetected and underserved.
Social workers ask clients questions about both the frequency and quantity of alcohol consumption for important reasons. For example, a social worker might ask, "Do you drink alcohol?"
1. Do you drink alcohol?
2. On average, how many days a week do you drink?
3. On a day when you drink, how many drinks do you usually have?
4. What is the maximum number of drinks you have had on any given occasion during the past month?
A positive response would be followed by a question concerning frequency, "On average, how many days a week do you drink?"
Questions concerning amounts consumed would also be in order, such as: "On a day when you do drink, how many drinks do you usually have?" and "What is the maximum number of drinks you consumed on any given occasion during the past month?"
These simple questions, posed in a direct but non-confrontational manner, allow the social worker to determine a client's risk for alcohol problems. This is based on recognition of the existence of a relationship between alcohol use and alcohol problems.
Questions about the quantity and frequency of drinking have been shown to have high sensitivity in detecting persons who drink above recommended limits (Adams, Barry, & Fleming, 1996).
Standards of Measure
If the answers to questions about amounts of alcohol consumption are to be meaningful, the interviewer must be aware that a standard drink contains about 14 grams (about 0.6 fluid ounces) of pure alcohol. The figure below depicts approximate standard drink equivalents
Note: People buy many of these drinks in containers that hold multiple standard drinks. For example, malt liquor is often sold in 16-, 22- or 40 oz. containers that hold between two and five standard drinks, and table wine is typically sold in 25 oz (750ml.) bottles that hold five standard drinks.
Another problem with quantity/frequency questions is that patients may understate their drinking, especially if they are alcohol dependent or are intoxicated at the time of the interview. Additional factors that can affect accuracy include clients' psychiatric problems, other medical problems, general level of cognitive functioning, the rapport between the client and the interviewer, assurance of confidentiality, and the client's awareness of what the interviewer knows from family member reports or laboratory data, such as results from a breathalyzer test (NIAAA, 1994).
Defining "At-RISK" Drinking
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) makes recommendations for moderate, safe alcohol use based on a number of factors, particularly the growing body of research studies linking alcohol use with morbidity and mortality from a number of causes. Binge drinking (usually defined as having 4 or more drinks on any one occasion) is an additional consideration in risk assessment, because it can lead to acute problems (accidents, violence, traffic fatalities) even though it may be sporadic. Furthermore, individuals who have family members who have been diagnosed with alcoholism must be made aware of their genetic risk in developing the disease.
The level of alcohol consumption that poses risks for developing alcohol-related problems is different for men and women, elderly people, children, teens, pregnant women, and individuals taking various medications.
- Men may be at risk if they have more than 14 drinks per week or more than 4 drinks on one occasion.
- A woman's risk is increased with more than 7 drinks per week or more than 3 drinks per occasion.
- A pregnant woman places her unborn child at risk for alcohol-related birth defects with any alcohol use.
- Due to decreases in muscle mass and metabolic changes, elderly individuals should limit their intake to no more than 7 drinks per week and no more than 1 drink per occasion.
- Children and adolescents should not drink at all, and any alcohol use should be an indication for further assessment according to the American Medical Association, Guidelines for Adolescent Preventive Services.
- Finally, alcohol interacts with numerous over-the-counter and commonly prescribed medications. The results of continuing to use any alcohol while taking these medications range from making the medication ineffective to severe illness and even death.
Binge drinking is an additional consideration in risk assessment, because it can lead to acute problems (accidents, violence, traffic fatalities) even though it may be sporadic. Binge drinking is defined as a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gram percent or above. For the average adult, this means consuming five or more drinks (male), or 4 more drinks (female), in about 2 hours.
Standard Screening Questionnaires
Most questionnaires that screen for alcohol problems focus either on the consequences (problems) of an individual's drinking behavior or on the individual's perceptions of their own drinking behavior (U.S. Preventive Services Task Force, 1996). Some of the most popular empirically-supported self-administered screening instruments include the CAGE, S-MAST, AUDIT, HSS, and computerized lifestyle questionnaires or surveys.
CAGE: The CAGE instrument is easy to remember and easy to score. It is both sensitive and specific for identifying persons who meet criteria for alcohol abuse and dependence (Buchsbaum, Buchanan, Centor, Schnoll, & Lawton, 1991; Soderstrom, Smith, Kufera, Dischinger, Hebel, & McDuff, et al., 1997). It consists of four questions. The "C" refers to cutting down: "In the past year, have you ever felt that you should Cut down on your drinking?" The "A" refers to the "Annoyance" question: "In the past year, have people Annoyed you by criticizing your drinking?" The "G" refers to a question on guilt: "In the past year, have you ever felt bad or Guilty about your drinking?" Finally, the "E" relates to using "eye opener" strategies to cope with aftereffects of alcohol abuse: "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)?"
CAGE: In the past year
1. have you ever felt that you should cut down on your drinking?
2. have people annoyed you by criticizing your drinking?
3. have you ever felt bad or guilty about your drinking?
4. have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover
One or more "yes" answers to these questions are associated with an increased risk of alcohol-related problems for both men and women. It should be noted that the CAGE has a tendency to miss some at-risk drinkers (Adams et al. 1996), most likely because it does not ask about current problems, levels of alcohol consumption, or binge drinking. The CAGE can easily be adapted to social work settings, and the questions can be made part of an overall assessment interview or questionnaire including a social history or intake interview.NIAAA Physicians' Guide: The NIAAA has developed a guide for use by primary care physicians to identify and intervene with alcohol problems among patients who enter their primary care medical clinics (NIAAA, 1995b). The Guide recommends using the CAGE questions (above), followed by questions concerning both quantity and frequency. This strategy provides the optimal balance in sensitivity and specificity (Dawson, 2000) and may be particularly useful in social work practice settings.
AUDIT: The Alcohol Use Disorders Identification Test (AUDIT) was developed from a World Health Organization (WHO) collaborative project that spanned six countries (Allen, Litten, Fertig, & Babor, 1997). Designed to detect hazardous alcohol consumption, the AUDIT is a 10-item questionnaire that asks about a client's alcohol consumption, drinking behavior, and alcohol-related problems over the past year.
Three of the questions in the AUDIT are drawn from the CAGE (questions C, A, and E). The other seven questions concern the quantity and frequency of drinking, binge drinking (defined in the AUDIT as having 6 or more drinks on a single occasion), blackouts, receiving advice from a health care professional regarding alcohol use, alcohol-related injury, and neglect of responsibilities due to alcohol use.
The AUDIT has a sensitivity of 50-80%. This varies depending on the population and the cutoff score used (Barry and Fleming 1993; Bohn, Babor, & Kranzler, 1995). One limitation of the AUDIT is that it may be less effective for detecting alcohol problems among people who barely meet the criteria for at-risk drinking. These include people who have two to three drinks per day and who binge drink once or twice a week (Schmidt, Barry, & Fleming, 1995). The AUDIT definition of binge drinking as being "6 or more drinks per occasion" is well above the at-risk drinking levels determined by the NIAAA. The length of the AUDIT makes it impractical to use in many settings as a primary screening instrument:
Please check the answer that is correct for you:
T-ACE and TWEAK: The T-ACE (Sokol, Martier, & Ager, 1989) and the TWEAK (Russell, Martier, Sokol, Mudar, Bottoms, & Jacobson, et al., 1994; Russell, Chan, & Mudar, 1997) tests were specifically developed to screen for alcohol problems among pregnant women. Both have been separately validated and found to have greater sensitivity than the CAGE. They can identify more than 80% of women who are drinking above recommended limits (Chan, Pristach, Welte, & Russell, 1993; Chang, Behr, Goetz, Hiley, & Bigby, 1997).
The T-ACE content includes questions similar to those in the CAGE but also addresses the possibility of emerging tolerance to alcohol. The first question is one of Tolerance, "How many drinks does it take to make you feel high?" The next is "Have people Annoyed you by criticizing your drinking?" This question is followed by "Have you ever felt you ought to Cut down on your drinking?" and the Eye opener question, "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?"
A total score of 2 or greater indicates potential risk for the purposes of Pregnancy Outreach Program identification of prenatal risk.
1. How many drinks does it take to make you feel high? Tolerance
1. less than or equal to 2 drinks
2. more than 2 drink
2. Have people annoyed you by criticizing your drinking? Annoyance
3. Have you felt you ought to cut down on your drinking? Cut Down
4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? Eye Opener
Total Score = _________
The TWEAK, on the other hand, asks about Tolerance in the following manner: "How many drinks can you hold?" This is followed by "Have close friends or relatives Worried or complained about your drinking in the past year?" and the Eye opener question, "Do you sometimes take a drink in the morning when you first get up?" The next question queries drinking-related Amnesia: "Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? " The final question completes the acronym with, "Do you sometimes feel the need to Kut down on your drinking?"
T Tolerance: How many drinks does it take to make you feel high? No. _____
(Record number of drinks)
Score 2 points if she reports 3 or more drinks to feel the effects of alcohol. Score:____
W Worry: Have close friends or relatives worried or complained about ____Yes
your drinking in the past year? ____ No
Score 2 points for a positive "yes". Score:____
E Eye-Opener: Do you sometimes have a drink in the morning when ____Yes
you first get up? ____ No
Score 1 point for a positive "yes". Score:____
A Amnesia (Blackouts): Has a friend or family member ever told you about ____Yes
things you said or did while you were drinking that you could not remember? ____ No
Score 1 point for a positive "yes". Score:____
K(C) Cut Down: Do you sometimes feel the need to cut down on your drinking? ____Yes
Score 1 point for a positive "yes". Score:____ ____ No
Total Score = _____ (A total score of 3 or more points indicates a likely drinking problem)
CHARM: Alcohol problems often go undetected in elderly clients because many conditions that may indicate a problem in this age group (such as dementia and depressive symptoms) are erroneously attributed to "the normal aging process." Recognition of older adults who may have alcohol use problems is facilitated through strong, coordinated working relationships with other service providers (i.e. visiting nurses, "meals on wheels" workers, home health aides, pharmacy staff, etc.) and family members who are likely to notice household or community problems. The CHARM questionnaire (Sumnicht, 1991) is a face-valid instrument that provides a clinically useful format for considering problems with alcohol and prescription medications among older clients. The acronym 'CHARM' was chosen for this particular age group to enhance the interviewer's awareness of the need to maintain a non-threatening, supportive approach.
- The questions begin with the letter "C" items, "Have you ever Cut down or quit drinking? When in your life would you say your drinking was the heaviest? Have you felt recently that you should Cut down?"
- Next, the letter "H" covers, "How do you use alcohol? What are your rules about alcohol use? Has your drinking changed in the last three months?"
- As in the instruments described above, "A" refers to "Has anyone ever seemed Annoyed about your drinking? People have different feelings about drinking alcohol; how do your friends and family view your drinking? Have you ever had health problems that caused your doctor to ask you to Alter your drinking habits?"
- The letter "R" addresses reasons for using alcohol: "Have you ever used alcohol to Relieve problems? (Looking for social or emotional discomfort such as loneliness or depression.) When you drink alcohol, what's usually the Reason? Do you ever have a drink when you feel lonely or upset? How is your sleep? What do you use to help you fall asleep?"
- Finally, the letter "M" addresses, "Do you ever drink More than you intended? What were the circumstances? Most people have times when they drink more than they intended to; what situations might cause you to drink More than you expected?"
RAFT/CRAFT and Other Tools for Screening Adolescents: The CAGE questionnaire for screening adolescents should be used with caution (Knight, 2001). However, a test based on the CAGE called the 'RAFT' was developed specifically for adolescents. It has not been fully validated, but preliminary studies look promising. It has been found to have a sensitivity of 89% and a specificity of 69% among adolescent outpatients (Bastiaens, Francis, & Lewis, 2000). The letter R refers to the adolescent's reasons for drinking: "Do you drink to Relax, feel better about yourself or to fit in?" The letter A asks about a red-flag situation, "Do you ever drink alcohol while you are Alone?" The letter F addresses the all-important issue of peer behavior: "Do any of your closest Friends drink?" Finally, the letter T refers to problematic outcomes associated with drinking, "Have you ever gotten into Trouble from drinking?"Another promising adolescent screening tool is the six-item CRAFT. A score of 2 or more has a sensitivity of 92% and a specificity of 82% for identifying adolescents who need intensive substance abuse treatment. The first question relates to a high-risk behavior often associated with adolescent drinking, "Have you ever ridden in a Car driven by someone (including yourself) who was "high" or who had been using alcohol or drugs?" The R and A are the same as the RAFT questions: ("Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?" and "Do you ever use alcohol or drugs while you are Alone by yourself?") The F refers to peers in a different way: "Do your family or Friends ever tell you that you should cut down on your drinking or drug use?" The last question is identical to the RAFT (Have you ever gotten into Trouble while you were using alcohol or drugs?"
Additional adolescent screening and assessment tools including the Adolescent Drinking Index (ADI), the Adolescent Alcohol Involvement Scale (AAIS), the Drug and Alcohol Problem Quick Screen (DAP), the Simple Screening Instrument for Alcohol and Other Drug Use (SSI-AOD), the Personal Experience Screening Questionnaire (PESQ), the Drug Use Screening Inventory (DUSI) and the Problem Oriented Screening Instrument for Teenagers (POSIT) are presented in the appendix. Social workers who are involved with teenage populations should be aware of these instruments and how they can be effectively used.
Clinical Laboratory Testing
Should clients be referred to a physician for a clinical laboratory test to detect alcohol use problems? It depends on the particular client situation. Obtaining blood alcohol concentrations is important in emergency rooms, trauma centers, and other acute care medical settings for confirming patients' self reports of alcohol use and for the medical management of patients who are about to undergo surgery. For screening purposes in social work practice, however, laboratory tests have not been found to be sufficiently sensitive or specific. In fact, these tests identify only about 10-30% of problem drinkers (Hoeksema & de Bock, 1993; U.S. Preventive Services Task Force, 1996). If it is strongly suspected that a client is alcohol dependent (from screening questions, family member reports, or records of legal, work, family or alcohol-related health problems), but you feel you are not getting accurate information from the individual directly, you may want to consider one of the following clinical lab options.
Lab Tests for Screening
- GGT: indicates liver injury
- MCV: elevated volume of red blood cells
- CDT: identifies heavy drinkers and relapse
GGT and MCV: Blood can be tested for concentrations of an enzyme called gamma-glutamyltransferase (GGT), which is an indicator of liver injury. Blood can also be tested for mean corpuscular volume (MCV), which provides an estimate of the volume of red blood cells and is often elevated in alcohol-dependent persons.
CDT: Another blood test, the carbohydrate-deficient transferrin (CDT) assay, helps to identify men who have been drinking more than five standard drinks per day for a year or more. It is significant at levels greater than 60 grams per day. This assay may also help to monitor abstinence (Huseby, Nilssen, Erfurth, Wetterling, & Kanitz, 1997). However, the test is not widely available and it has been found to perform poorly (especially false positives) among women (Gronbaek, Henriksen, & Becker, 1995; Stauber, Vollmann, Peserl, Jauk, Lipp, & Halwachs, et al., 1996), binge drinkers (Lott, Curtis, Thompson, Gechlik, & Rund, 1998), persons with liver disease (Stauber, Stepan, Trauner, Wilders-Truschnig, Leb, & Krejs, 1995), and those who have been drinking intermittently during the past 12 months (Anton & Bean, 1994). For these reasons, CDT may be more useful for monitoring relapse among high-risk patients than as a routine screening measure. For more information concerning the use of biological tests see "Biological Assessment of Alcohol Consumption," in Assessing Alcohol Problems: A Guide for Clinicians and Researchers (NIAAA, 1995a).
Screening for alcohol problems can take place in a variety of settings. These include the initial interview with a client or family, during office visits or telephone contacts, home visits, or other face-to-face encounters. To increase the likelihood for getting accurate information, it is important to establish an atmosphere of trust. As a social worker who has been trained in interviewing and clinical skills, you must use all of these to determine if your client has an alcohol problem, and if it is impacting on the client's other problems in living.
It is important to remember that determining if a client may be alcoholic or alcohol dependent is not the only goal. It is most helpful to find out if this person drinks, and if so how they use alcohol now and in the past and whether there are problems with family, friends, work or health that may be related to drinking (Savitsky, 1987). In particular, it is important to integrate the screening functions with an assessment of other types of problems associated with alcohol use. This includes assessing for health problems, assessing for family, social and employment problems, and assessing for evidence of physical dependence on alcohol.
Assess for other problems associated with alcohol use:
- Physical dependence
Four steps for alcohol screening and engagement of a client in a brief intervention include:
Step I - Ask about Alcohol Use
- Consumption (drinks per week and per occasion)
If consumption is:
Men: >14 drinks/wk or > 4/occasion
Women: > 7 drinks/wk or >3/occasion
Men & Women: CAGE score 1 or more
Step II - Assess for alcohol-related problems
- Alcohol dependence
- Readiness to change
Step III - Advise Appropriate Action
- Advise to abstain
- Refer to a specialist
- Consider pharmacotherapy
Alcohol-related problems or at risk for developing problems
- Advise to cut down
- Set a drinking goal
- Consider pharmacotherapy
RECOMMENDED CLASSROOM ACTIVITIES
- Locate and/or identify at least one evidence-based alcohol problems screening device (including those detailed in this module). Role play its use with different types of clients:
(a) A 28-year-old mother experiencing prolonged bouts of depression since the birth of her 3rd child;
(b) A 24-year-old single man who is being discharged from the hospital following a serious automobile crash in which he was the sole occupant of a car that hit a tree;
(c) A 77-year-old man who has been caught stealing a single bottle of whiskey from a grocery store;
(d) An 18-year-old woman who failed her first two semesters at college;
(e) A 44-year-old professional who has always entertained clients at luncheons, dinner, and sporting events but is losing his sales position because of poor job performance;
(f) A 20-year-old pregnant woman at intake to a neighborhood-based multiple services program for low-income single parents.
Discuss the appropriateness of the instrument for this type of person. Discuss the research that supports and/or refutes its usefulness.
- Design a study that would allow you to determine whether or not your instrument is sensitive and specific in application to the population represented by one of the role-play characters (a-f) above. What would your sample have to look like? What methodological concerns would arise? What validating tools would you want to include?
- Imagine that your agency director wants to pursue a grant that requires all service providers to conduct alcohol use problem screenings on all clients at intake. You are required to develop a presentation to your colleagues in the agency that will:
(a) convince them of the necessity of doing such screenings-for the client's welfare;
(b) teach them how to pick a screening device;
(c) alert them to the practices that make these screenings most effective and those that interfere with effectiveness. Develop it and present it.
- Discuss what are the appropriate next steps when a client's screening result is "positive" for an alcohol use problem.
- Discuss the legal, ethical, and methodological issues involved with ordering clinical laboratory testing for alcohol levels on a client. When should and/or should not such testing be conducted?
- Discuss the ways in which screening data can and should be used in "macro" social work practice. For example, how can the data inform local and regional public policy? How can the data shape program development? How can and should this type of data be incorporated into program evaluation practices? What are the limitations of using these kinds of data in these ways?
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Updated: March 2005