Screen and Assess: Use Quick, Effective Methods

Screening for unhealthy alcohol use, combined with a brief intervention when needed, is a top preventive service in terms of potential health impacts and cost effectiveness. 1 Many healthcare professionals may feel uncomfortable asking patients about their drinking, however, and may be concerned that the answers could raise issues that require more time, resources, and knowledge than they can offer. 2,3

Here, we describe quick, effective alcohol screening tools and clear steps to take depending on patient answers. You may increase comfort levels for yourself and your patients by making this process routine and by reassuring patients that “we ask everyone.” To help with follow-up, we provide links to other Core articles, resources, and an interactive, simplified sample workflow.

A note on drinking level terms in this Core article: The 2020-2025 U.S. Dietary Guidelines states that for adults who choose to drink alcohol, women should have 1 drink or less in a day and men should have 2 drinks or less in a day. These amounts are not intended as an average but rather a daily limit. Heavy drinking has been defined for women as 4 or more drinks on any day or 8 or more per week, and for men as 5 or more drinks on any day or 15 or more per week.

Why is it important to ask about alcohol use?

Here are four good reasons to talk with your patients about their use of alcohol:

• Alcohol use contributes to common health problems: Heavy alcohol use can increase the odds for injuries and other acute problems as well as chronic illnesses such as liver disease, hypertension, and depression. 4–6 Alcohol use can promote disease progress while compromising self-care and treatment outcomes. Even alcohol use within the U.S. Dietary Guidelines is not risk-free, as it can raise cancer risks and interact with medications. 7 (See Core articles on medical complications and medication interactions.)
• Alcohol screening and brief intervention can reduce drinking levels: Research has demonstrated that brief interventions with patients who screen positive for heavy drinking can reduce alcohol use and is cost effective in primary care settings. 8–12 Based on estimates of cost-effectiveness and preventable disease burden, alcohol screening and brief intervention ranks higher than other common preventive practices such as screening for hypertension, high cholesterol, and cancer. 1
• Early detection averts greater harm: It’s a myth that people who drink heavily or have AUD need to hit “rock bottom” before changing their drinking patterns. As with any other health condition, it’s better to prevent alcohol problems from developing or to treat them before they become severe.
• Asking about alcohol may help an entire family: Family members of those with alcohol use disorder (AUD) have more health problems and more costly medical care than family members of those without AUD, 13 or even those with other chronic medical problems. 14 Thus, identifying individuals with alcohol problems may make a difference in the whole family’s health.

Who should conduct screening?

Any healthcare professional in medical or mental health fields can easily screen for heavy drinking 15–18 as part of a comprehensive assessment or health history. In primary care, teams that include nurses and other non-physician providers are increasingly used for alcohol screening. Patient self-reporting on paper, a tablet, or online (such as through a patient portal) may provide more accurate answers than asking directly. 19,20 Regardless of how screening is administered, entering the results into the patient’s medical chart or electronic health record (EHR) can facilitate collaborative care.

What quick and effective screening questions should I ask?

Because of time pressures, it is practical for primary care professionals to use a brief screener that asks about heavy drinking days, then to ask follow-up questions as needed.

• Do use:
  • For adults, the U.S. Preventive Services Task Force (USPSTF) recommends using one of the following two brief tools, noting that they have good sensitivity and specificity across the spectrum of unhealthy alcohol use. 21 Each tool asks about heavy drinking days and requires only 1-2 minutes to administer.
    • The Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) consists of three questions related to drinking frequency and quantity. Responses can be scored with a paper form or within the EHR. The higher the score, the more likely alcohol is affecting a patient's health and safety. 22 (Note: The AUDIT-C questions are a subset of the full 10-question AUDIT [PDF – 172 KB]. A USA­­UDIT version is adapted for U.S. standard drink sizes and limits.)
    • The NIAAA Single Alcohol Screening Question (SASQ) is “How many times in the past year have you had (4 for women, or 5 for men) or more drinks in a day?” A response of one or more warrants follow-up (see the section “When patients screen positive…,” below). Because it is not a scored instrument, the SASQ can be woven easily into a verbal clinical interview. Before asking the SASQ, you can ask a prescreen along the lines of “How often did you have a drink containing alcohol in the past year?”
    • Avoid “yes/no” or leading questions such as “Did you drink (4 for women, or 5 for men) drinks at one sitting?” or “You don’t drink very often, do you?”
    • Avoid the still widely used but outdated “CAGE” as a screening tool (CAGE is an acronym for four questions: Cut down, Annoyed, Guilty, Eye-opener). The USPSTF does not recommend the CAGE for screening because it does not identify all patients who could benefit from a brief intervention. 21,23 The CAGE only captures patients already experiencing adverse consequences of heavy drinking, so you miss many prevention opportunities. 23

    Are laboratory tests available to screen for or monitor alcohol problems?

    Laboratory tests are not a substitute for drinking self-report measures, but they can serve as an objective means to help identify whether patients drink heavily or have alcohol-related health problems. 24 Discussing the results of initial and follow-up testing with patients may also help motivate them and reinforce their progress in treatment. 25 Older and more readily measurable biomarkers such as serum gamma-glutamyl transferase (GGT) and serum carbohydrate-deficient transferrin (CDT) indirectly reflect alcohol consumption, whereas some newer assays directly measure alcohol metabolites such as serum phosphatidyl ethanol (PEth) and urinary ethyl glucuronide (EtG). 26,27

    See the Resources section below for a helpful advisory on how these and other biomarkers can help support alcohol screening, motivate patients to change drinking behavior, and identify returns to heavy drinking that often occur in recovery, so that you can encourage patients to get back on track. (See Core article on recovery.) The advisory includes information on each test’s window of assessment and sensitivity and specificity.

    When patients screen negative for heavy drinking days, how can I build on that response to reduce future risks?

    When patients who drink alcohol screen negative for heavy drinking days, reinforce or advise that they stay within U.S. Dietary Guidelines of 1 drink or less in a day for women and 2 drinks or less in a day for men. 24 Help patients understand that these guidelines are not intended as an average but instead a limit for any single day, 24 and that current research indicates, essentially, “the less, the better.” 25,26

    Be alert to pregnancy and other health conditions that may warrant advice to not drink at all. (See Core articles on medical complications and medication interactions.) Patients who currently do not drink alcohol are advised by the Dietary Guidelines not to start for their health or “for any reason.” 24

    When patients screen positive for heavy drinking days, what are my next steps?

    Following a positive screen, ask a few questions to get a more complete picture of the patient’s drinking pattern and determine whether the patient has symptoms of AUD.

    • Ask about the typical weekly drinking pattern. The more frequent the heavy drinking days, and the greater the weekly volume, the greater the risk of having AUD. 27 To learn the typical weekly pattern, ask, “On average, how many days a week do you drink alcohol?” and “On a typical drinking day, how many drinks do you have?” Multiply the answers to get the typical weekly amount, which will serve as a baseline for follow-up. Keep in mind that heavy weekly drinking is defined as 8 or more drinks for women and 15 or more for men.
    • Conduct a quick AUD assessment to determine the next steps. Assessment instruments can be used efficiently through EHRs or by self-report. Among the possible tools, an 11-item Alcohol Symptom Checklist [PDF – 147.8 KB] based on the diagnostic criteria for AUD has the advantage of directly providing a diagnosis and level of severity. Below are the criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 28 Mild AUD is 2-3 symptoms, moderate AUD is 4-5 symptoms, and severe AUD is 6 or more symptoms.
      1. Alcohol is often taken in larger amounts or over a longer period than was intended.
      2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
      3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
      4. Craving, or a strong desire or urge to use alcohol.
      5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
      6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
      7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
      8. Recurrent alcohol use in situations in which it is physically hazardous.
      9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
      10. Tolerance, as defined by either of the following:
          1. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
          2. A markedly diminished effect with continued use of the same amount of alcohol.
      11. Withdrawal, as manifested by either of the following:
          1. The characteristic withdrawal syndrome for alcohol (See the “How is alcohol withdrawal managed?” section for some DSM-5 symptoms of withdrawal).
          2. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

    Many patients with AUD may also experience dysphoria and irritability when the effects of alcohol are wearing off. (See Core article on neuroscience.)

    Patient responses to assessment questions offer opportunities to engage them in exploring their own reasons for making a change in their drinking. (See Core article on brief intervention). Routinely integrating an Alcohol Symptom Checklist [PDF – 147.8 KB] into primary care may make it easier for healthcare professionals to hold comfortable, patient-centered, non-judgmental conversations about alcohol that help destigmatize AUD and its treatment. 29–31

    After assessing for AUD, what are my next steps?

    After you assess your patients for AUD, advise and assist them toward cutting back or quitting. Here are the next steps in brief (these are spelled out in more detail in other Core articles):

    • For patients who drink heavily and do not have AUD: Offer brief advice to cut back to the Dietary Guidelines levels or to quit if medically indicated. If a patient is hesitant to accept that drinking goal at first, then negotiate an individualized, initial goal, such as cutting back significantly, ideally to include no heavy drinking days, with an ultimate goal of cutting back to Dietary Guidelines levels or abstaining if indicated. Follow up at the next visit.
    • For patients who have AUD: Advise abstinence and emphasize that it’s important to cut down gradually because suddenly stopping can result in alcohol withdrawal, which can be life threatening (see Core article on AUD). Be cautious and consider the need for medically managed withdrawal. Again, if the patient is hesitant to abstain, then negotiate individualized drinking goals, with, for example, a starting goal of no heavy drinking days and an ultimate goal of abstaining or cutting back to the Dietary Guidelines levels. Discuss evidence-based professional treatment as well as mutual support group options. Consider support in primary care with FDA-approved AUD medications, which are easy to prescribe, and regular follow-ups. Consider referral to specialty care, especially for patients with mental health comorbidities or more severe AUD. Follow up at the next visit.

    For tips on holding these conversations with patients using motivational interviewing, see the Core article on brief intervention. For other practical insights on how to help your patients with AUD, see also the Core articles on treatment, referrals, and recovery.

    In closing, with a few brief questions, you can determine whether your patients are drinking at levels that may have adverse health effects and whether, in addition, they have symptoms of AUD. From there, you’ll be able to set a clear path to help improve your patients’ risk profile, health, and wellbeing. An interactive, simplified sample workflow for this process is linked below.