Screening and Assessment

Key Points

• Apply CAGE screening to all patients older than 18.

• Be aware of "negative" drinking history.

• Closely follow up positive responses.

• The AUDIT-C is a standard for quantifying alcohol use disorders in medical settings.

There is good evidence to support screening for alcohol dependency and alcohol use disorders when using standard screening tools in practice. For the family physician, the diagnosis of alcoholism often depends on clues from the history and physical examination (Box 49-1). Possible clues may include a history of driving under the influence (DUI) or an MVC; history of repetitive trauma; new-onset hypertension, gastritis, or pancreatitis; other, otherwise unexplained liver disease (AST > ALT); presence of depression; recent loss of employment or separation from family; unexplained tremor; upper gastrointestinal (GI) bleeding; recent falls or accidents; and a history of family or marital violence.

The four CAGE questions (cut down, annoyed, guilty, eye opener) are adequate for screening purposes (Box 49-2), derived from the longer Michigan Alcoholism Screening Test (MAST) questions (see eTable 49-1 online) (Hays and Spickard, 1987; Powers and Spikard, 1984). Two positive responses are considered a positive screen and indicate that further assessment is warranted. An important point is that family physicians should not assume that someone does not have an alcohol use disorder when that person answers negatively to questions about drinking. If such patients do not use alcohol at all, it may indicate that they had to quit because they had problems with alcohol. Given the prevalence of alcohol use disorders, it is recommended that the CAGE questions be applied to all patients older than 18 years. Another brief set of screening questions is the TWEAK questionnaire: tolerance, worries, eye openers, amnesia, and cut down (Box 49-3).

Longer screening questionnaires include the MAST and the Alcohol Use Disorders Test (AUDIT: see eTable 49-2 online) (Saunders et al., 1993). Both are considered higher in predictive value but more difficult to administer. Age-specific and population-specific survey tools are also available, including the Geriatric Alcoholism Screen and an adolescent alcoholism inventory. The 10-item Core questionnaire includes three questions on alcohol consumption (the AUDIT-C) and seven on the impact of alcohol use. The AUDIT has been shown to have good sensitivity and specificity in

Box 49-1 Screening Clues for Alcoholism

"Driving under the influence" (DUI) arrest

Domestic violence

Unexplained trauma

Family stress

New hypertension




Box 49-2 Brief Screening Questions for Alcohol Use


1. Have you ever felt 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 to get rid of a hangover (eye opener)?

Scoring: Item responses on the CAGE are scored 0 for "no" and 1 for "yes" answers, with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant.

The normal cutoff for the CAGE is two positive answers; however, the Consensus Panel recommends that the primary care clinicians lower the threshold to one positive answer to cast a wider net and identify more patients who may have substance abuse disorders. A number of other screening tools are available.

CAGE Questions Adapted to Include Drugs (CAGE-AID)+

1. Have you ever felt you ought to cut down on your drinking or drug use?

2. Have people annoyed you by criticizing your drinking or drug use?

3. Have you felt bad or guilty about your drinking or drug use?

4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

*Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1984;252:1905-1907. tBrown RL, Rounds LA. Conjoint screening questionnaires for alcohol and drug abuse. Wis Med J 1995;94:135-140.

medical and general populations and has recently been useful for screening patients with major psychiatric disorders and as an assessment instrument for patients seeking treatment for alcohol use disorders (Cassidy et al., 2008; Donovan et al., 2006). The AUDIT-C provides an efficient standardized method for assessing the quantity and frequency of alcohol use and accounts for much of the test's discriminative power in medical populations (Rodriguez-Marros and Santamarina, 2007).

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