skip to content National Cancer Institute
National Cancer Institute U.S. National Institutes of Health www.cancer.gov
You are not logged in. Why register?
 
  Construct Details
  
Construct Name: Risky Drinking
Definition of Construct: Excessive drinking behavior
Theoretical Foundation:
Synonyms for Construct: Alcohol Use Disorder, Binge Drinking
Similar Constructs: drug use, unhealthy alcohol use
Associated Constructs addiction
Keywords: EHR Candidate, alcohol, at-risk drinking, heavy drinking, alcohol abuse, alcoholism, unhealthy alcoh

ReferencesPubMed IDComment
  

MeasuresDatasets
AUDIT-C (Alcohol Consumption Questions)
(Last Updated: 4/12/2011 10:39:44 AM by Maureen Boyle)


  Comments (6 comments)
  
Target for health intervention is Unhealthy Alcohol Use, 4/8/2011 11:41:19 AM
By Richard Saitz, Boston University & Boston Medical Center
Please see comment posted under unhealthy alcohol use which includes the range of alcohol use that affects health from use of amounts that risk consequences all the way through the severest, alcohol dependence.

For detecting unhealthy alcohol use, while the AUDIT is well-validated, it has proven too long for widespread use in most primary care settings. The AUDIT-C is certainly robust and well-validated (one minor limitation is the need for scoring of the multiple response option questions). Another alternative is a single item screening tool, which is currently recommended by NIAAA. The CAGE items, although well known, are not used in primary care settings widely, and are limited greatly because they focus on dependence, which is not the main or only target of screening (the target is laregly nondependent unhealthy use).

http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/Pages/guide.aspx and JOURNAL OF GENERAL INTERNAL MEDICINE Volume 24, Number 7, 783-788, DOI: 10.1007/s11606-009-0928-6. Primary Care Validation of a Single-Question Alcohol Screening Test. Smith PC, Schmidt S, Allensworth-Davies D, Saitz R.
EHR Campaign Evaluation, 4/4/2011 3:32:04 PM
By Jessica Kasirsky, NextGen Healthcare

Measure Ratings

No measures rated.

Recommendations

Audit C and CIDI-II both require a license. This should be taken into account when choosing a survey tool.
CAGE Alone Inadequate; Stepped Screening with AUDIT-C recommended, 4/3/2011 4:54:12 PM
By Katharine Bradley, Group Health Research Institute
The CAGE is a screen for alcohol use disorders and does not screen for risky drinking/excessive alcohol use.( 1) Many patients who screen positive may no longer drink alcohol.(2) Because brief interventions have been demonstrated efficacious for risky drinking,(3) are recommended by USPSTF,(4) and were designated the third highest prevention priority for US adults,5 alcohol screening supported by EHRs should not be limited to the CAGE.
1. Buchsbaum DG, Buchanan R, Centor R. Interpreting CAGE scores. Ann. Intern. Med. 1992;116(12):1032-1033.
2. Bradley KA, Maynard C, Kivlahan DR, McDonell MB, Fihn SD. The relationship between alcohol screening questionnaires and mortality among male veteran outpatients. J. Stud. Alcohol. Nov 2001;62(6):826-833.
3. Kaner EF, Dickinson HO, Beyer F, et al. The effectiveness of brief alcohol interventions in primary care settings: A systematic review. Drug Alcohol Rev. May 2009;28(3):301-323.
4. Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. Preventive Services Task Force. Ann. Intern. Med. 2004;140:557-568.
5. Solberg LI, Maciosek MV, Edwards NM. Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness. Am. J. Prev. Med. Feb 2008;34(2):143-152.

Risky Drinking is a synonym for excessive alcohol use. I am therefore also posting here, a comment I submitted on excessive alcohol use: Evidence-based EHR should support stepped screening and assessment for excessive alcohol use and misuse, as well as follow-up assessment, and should allow integration of alcohol use and misuse data with other elements of the EHR. Specific recommendations and issues are addressed below.


1. Any Alcohol Use
EHRs should allow documentation of any alcohol use (1 question) using a validated screen for any drinking in the past year. I recommend, and VA uses, the first question of the WHOs AUDIT. We have validated this approach to alcohol screening (only screening those who report drinking on AUDIT question #1.(1)


2. Typical and Binge Drinking
EHRs should allow documentation of typical drinking as well as binge drinking with the 2nd and 3rd AUDIT questions. I recommend and VA uses, the second and third question of the AUDIT. I recommend modifying the 3rd question of the AUDIT, to ask about the frequency of drinking 4 or more drinks on an occasion for women and 5 or more for men, as recommended by many experts, so that it is consistent with US drink sizes and gender-specific recommendations. We have validated the female-specific variation,(2) whereas the US version of AUDIT question #3 for men is consistent with other US single-item binge questions.(3)


3. AUDIT-C Score
The AUDIT-C should be incorporated and automatically scored in the EHR in a way that scores can be tracked over time (table, worksheet or graph). I recommend that the score of the first 3 AUDIT questions (called the AUDIT-C for Consumption) be used as the screen for alcohol misuse. In addition, to reporting the typical reported alcohol consumption (AUDIT Q#2), and frequency of binge drinking (AUDIT Q#3), and a positive or negative screen (Yes/no) in the EHR, the AUDIT-C score should be calculated by the EHR and documented and can be viewed over time. The AUDIT-C score has been shown to be associated with alcohol-related symptoms on the remainder of the AUDIT, self-management of hypertension and diabetes, and medication adherence, as well as risk for alcohol dependence, hospitalizations for GI complications of drinking, fractures, potentially preventable hospitalizations, surgical complications, and death.(4-11)

i. What is a positive screen? A positive screen should be considered any patients who screen positive on the AUDIT-C score (>= 3 for women and >= 4 for men)1 OR report of binge drinking in the past year on the gender-specific version of the AUDIT-C question #3.(3) This is easily calculated by the EHR.

ii. Why we recommend the AUDIT-C over single-item binge questions for EHRs: The AUDIT-C includes a binge question (Q#3) but also provides important information on typical drinking. Many medical conditions and medications are impacted by and/or interact with typical alcohol use. Therefore, medical providers would want to know if men drink 3-4 drinks weekly or more often (non-binge drinking), which could complicate health care (e.g. hypertension, hepatitis C, or anticoagulation).

iii. Why we recommend the AUDIT-C be included even if the full 10-item AUDIT is also included: The AUDIT-C is as effective a screen for excessive use or DSM-IV alcohol use disorders as the full 10-item AUDIT, (1,12) and has been found feasible for routine administration in VA. (13,14) In the mid-1990’s we sought a briefer alcohol screen than the full AUDIT when we were not permitted to implement the 10-AUDIT in a VA primary care clinic due to its length. Others have used the AUDIT-C,(15) reflecting that it is likely a more practical first line screen in many primary care settings.

iv. Why isn’t patient report of drinking better than having to score as screen? The use of the AUDIT-C score is essential because questions about typical drinking underestimate alcohol consumption. For example, in VA only 54% of male patients who drank over 14 drinks a week reported doing so on the AUDIT’s questions #1-2.


4. Optional further assessment.
Optional assessment tools that might help the primary care provider engage patients include: the remaining 7 questions of the AUDIT and the 10-item AUDIT score, DSM-IV criteria for alcohol use disorders; and readiness to change questions (on 10 point likert scales about importance, confidence and intention; “readiness rulers”).

5. Essential data integration.
i. Data on past year alcohol use (any use) and alcohol screening scores (0-12) should be integrated with other data elements for patient safety. This would allow identification of patients needing outreach due to drinking despite contraindications (i.e. patients with alcohol use disorders, alcoholic diagnoses such as cirrhosis or cardiomyopathy, hepatitis C, etc.) and identification of patients at risk for important medication interactions (e.g. warfarin, methotrexate, etc.)

References
1. Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol. Clin. Exp. Res. Jul 2007;31(7):1208-1217.
2. Bradley KA, Bush KR, Epler AJ, et al. Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch. Intern. Med. Apr 14 2003;163(7):821-829.
3. Bradley KA, Kivlahan DR, Williams EC. Brief approaches to alcohol screening: practical alternatives for primary care. J. Gen. Intern. Med. Jul 2009;24(7):881-883.
4. Rubinsky AD, Kivlahan DR, Volk RJ, Maynard C, Bradley KA. Estimating risk of alcohol dependence using alcohol screening scores. Drug Alcohol Depend. Apr 1 2010;108(1-2):29-36.
5. Bradley KA, Kivlahan DR, Zhou XH, et al. Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients. Alcohol. Clin. Exp. Res. Mar 2004;28(3):448-455.
6. Bryson CL, Au DH, Sun H, Williams EC, Kivlahan DR, Bradley KA. Alcohol screening scores and medication nonadherence. Ann. Intern. Med. Dec 2 2008;149(11):795-804.
7. Au DH, Kivlahan DR, Bryson CL, Blough D, Bradley KA. Alcohol Screening Scores and Risk of Hospitalizations for GI Conditions in Men. Alcohol. Clin. Exp. Res. Mar 2007;31(3):443-451.
8. Harris AH, Bryson CL, Sun H, Blough D, Bradley KA. Alcohol Screening Scores Predict Risk of Subsequent Fractures. Subst. Use Misuse. Jun 17 2009;44:1055-1069.
9. Chew RB, Bryson CL, Au DH, Maciejewski ML, Bradley KA. Are smoking and alcohol misuse associated with subsequent hospitalizations for ambulatory care sensitive conditions? 2011.
10. Bradley KA, Rubinsky AD, Sun H, et al. Alcohol Screening and Risk of Postoperative Complications in Male VA Patients Undergoing Major Non-cardiac Surgery. J. Gen. Intern. Med. Sep 28 2010.
11. Harris AHS, Reeder R, Ellerbe L, Bradley KA, Rubinsky AD, Giori NJ. Preoperative Alcohol Screening Scores are Associated with Number of Surgical Complications in Male Total Joint Arthroplasty Patients. The Journal of Bone and Joint Surgery. In Press.
12. Kriston L, Holzel L, Weiser AK, Berner MM, Harter M. Meta-analysis: are 3 questions enough to detect unhealthy alcohol use? Ann. Intern. Med. Dec 16 2008;149(12):879-888.
13. Bradley KA, Williams EC, Achtmeyer CE, Volpp B, Collins BJ, Kivlahan DR. Implementation of evidence-based alcohol screening in the Veterans Health Administration. Am. J. Manag. Care. Oct 2006;12(10):597-606.
14. Lapham GT, Achtmeyer CE, Williams EC, Hawkins EJ, Kivlahan DR, Bradley KA. Increased Documented Brief Alcohol Interventions With a Performance Measure and Electronic Decision Support. Med. Care. Sep 28 2010.
15. Rose HL, Miller PM, Nemeth LS, et al. Alcohol screening and brief counseling in a primary care hypertensive population: a quality improvement intervention. Addiction. Aug 2008;103(8):1271-1280.
AUDIT better, 3/26/2011 1:39:11 PM
By Jennifer Hodgson, East Carolina University
I like the AUDIT better as it is validated and normed for a more diverse patient panel. I would also recommend adding the CRAFFT if we are considering adolescent populations.
Stephen Taplin MD, MPH, 3/15/2011 12:45:06 PM
By Stephen Taplin, NCI
The CAGE questionnaire for alcohol is widely used in primary care. The use of a more general item that gets at alcohol, tobacco, and drugs is desirable but it would have to overcome historic practice and show its association with people at risk of addiction.
Health Policy Committee Statement, 2/25/2011 10:43:11 AM
By Anna Adachi-Mejia, Dartmouth Medical School
The NIDA National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) has ongoing and planned consultations with federal, state, community and industry stakeholders to reach a consensus on a core set of standardized measures for Tobacco, Alcohol, and Substance Use Disorders (SUD) in an Electronic Health Record (EHR). These measures are intended to serve as resources for vendors incorporating these measures into EHR products, with the intent of supporting interoperability and data exchange in a developing National Health Information Network (NHIN). The initial focus is on the primary care setting, with extension to specialty treatment planned for 2011. In order to avoid duplication of effort this initiative has been synchronized with the current initiative being led by NCI and OBSSR. Therefore we will be recommending the tobacco, alcohol use and substance abuse screening tools that are being developed by NIDA.


Draft core measures proposed for primary care include a brief integrated screener for tobacco, alcohol and drug abuse, with additional assessment questions administered depending on the screening severity index. This draft core is being developed to collect only a minimal essential data set for clinical primary care and is based on review of information solicited from standard community treatment and health organization intake forms, SUD standardized instruments, and recommendations from specialty and primary care experts and other stakeholders engaged at a focused workshop, symposium and other meetings.


NIDA will be presenting and discussing these measures at the ‘Identifying Core Behavioral and Psychosocial Data Elements for the Electronic Health Record’ meeting on May 2nd in Bethesda, MD. In the meantime, participants in the EHR Campaign are encouraged to provide any comments in regards to assessing this construct through GEM---see instructions for how to provide feedback.