Popular questionnaires to screen for alcohol misuse include the CAGE, the TWEAK, and the short form of the Alcohol Use Disorder Identification Test (AUDIT-C). Any of these is recommended. The important thing is to be proactive about screening for this very common and underrecognized problem.
A COMMON PROBLEM, NOT OFTEN ADMITTED
Alcohol use disorder, which ranges from hazardous drinking to binge drinking and alcohol dependence, is more common than admitted and often goes undiagnosed. Its personal, societal, and economic consequences cannot be overemphasized. Alcohol use is responsible for 85,000 deaths each year in the United States, and it is linked to substantial medical and psychiatric consequences and injuries, especially motor vehicle accidents. The estimated annual cost of problems attributed to alcohol use is over $185 billion.1
About three in 10 US adults drink at levels that increase their risk for alcohol-related consequences, and about one in four adults currently abuses alcohol or is dependent on it.2 In 2009, 6.8% of the US population age 12 and above reported heavy drinking, with highest rates in those ages 21 to 29.3 The rate of alcohol use was higher in men than in women, but about 10% of pregnant women ages 15 to 44 reported current alcohol use.3
The prevalence of alcohol use disorder ranges from 2% to 29% in a typical ambulatory primary care medical practice.4 And only one-third of people with alcohol use disorder are diagnosed.
Studies and experience have shown that problem drinkers tend to not seek help until they have advanced dependence, often with associated medical and sociolegal complications. It is also well established that the earlier the diagnosis is made and appropriate intervention is offered, the better the prognosis.
WHAT IS THE GOAL OF SCREENING?
The goals of screening for alcohol use disorder are to estimate the patient’s risk level, to identify those at risk because they exceed defined limits, and to identify those with evidence of an active problem, ie, with adverse consequences related to their drinking. This screening paves the way for further assessment, definitive diagnosis, and a treatment plan.
The US Preventive Services Task Force recommends screening and behavioral counseling interventions (such as a brief intervention) in the primary care setting to reduce alcohol misuse by adults, including pregnant women.5 In addition, most primary care patients who screen positive for heavy drinking or alcohol use disorder show motivation and readiness to change, and those with the most severe symptoms tend to be the most ready.6
THE IDEAL QUESTIONNAIRE: SENSITIVE, SPECIFIC, AND SHORT
The ideal alcohol screening questionnaire for a busy practice should be brief and highly sensitive and specific for identifying the spectrum of alcohol misuse. Also, it should be easy to recall so it can be part of routine face-to-face discussion with the patient during an office visit.
Further, it should include questions that focus on the consequences of drinking as well as on quantity and frequency. It should also take into account factors such as the patient’s age, sex, race or ethnicity, and pregnancy status, as these can influence the effectiveness of the screening method.
Problems with focusing on quantity alone
“Risky use” is defined (in a non-alcohol-dependent person or one with no alcohol-related consequences) as more than seven standard drinks per week or more than three per occasion for women, and more than 14 standard drinks per week or more than four per occasion for men.2
A standard drink in the United States contains about 12 to 14 g of ethanol: a 12-oz can or bottle of beer, a 5-oz glass of wine, or about 1.5 oz of 80-proof liquor.2
The common single-item screening test asks, “How many times in the past year have you had more than four drinks (for women) or five drinks (for men) in a day?” This is recommended by the National Institute on Alcohol Abuse and Alcoholism for brief screening in primary care. However, a positive answer (ie, one or more times in the past year) has a sensitivity of only 82% and a specificity of only 79% for detecting unhealthy alcohol use, and an even lower specificity (67%) for detecting current alcohol use disorder.7
The CAGE questionnaire
The four-item CAGE questionnaire8 focuses on the consequences of drinking:
- C: Have you felt the need to cut down on your drinking?
- A: Have you ever felt annoyed by someone criticizing your drinking?
- G: Have you ever felt bad or guilty about your drinking?
- E: Have you ever had an eye-opener—a drink the first thing in the morning to steady your nerves?
A yes to one or more of the questions denotes a need for further assessment.
The CAGE questionnaire is simple, non-threatening, brief, and easy to remember. A yes answer to two or more items has a sensitivity of 75% to 95% and a specificity of 84% to 97% for alcohol dependence.9 However, CAGE is less sensitive for identifying nonalcohol-dependent at-risk drinkers. The patient’s sex and ethnicity have also been found to affect its performance somewhat, with some studies showing a sensitivity as low as 50% in adult white women and as low as 40% in at-risk groups ages 60 and over.