Canadian Task Force on Preventive Health Care

Full Text Review

Early Detection and Counselling of Problem Drinking

These recommendations were finalized by the Task Force in March 1994

 Contents

Overview

In 1989 the Canadian Task Force on the Periodic Health Examination concluded that there was fair evidence that routine case-finding for problem drinking, and that brief counselling intervention in patients identified thereby was effective in reducing alcohol consumption and related consequences.< 1,2> The studies which yielded this evidence<3,4> have since been confirmed by seven new randomized controlled trials<5- 11> in study populations that included both men and women aged 18-60 years. Standardized interviewing strategies and questionnaires are more sensitive than clinical judgement and can be used routinely with all adults to raise the index of clinical suspicion of problem drinking. When problem drinkers are identified, either simple advice or brief counselling is effective in reducing alcohol consumption and diminishing the negative consequences of drinking. The intervention of simple advice or brief counselling is appropriate for the patient with mild to moderate as opposed to severe alcohol dependency. Problem drinking or mild to moderate, rather than severe dependency is the focus of this report. There are separate chapters on Primary Prevention of Fetal Alcohol Syndrome (alcohol consumption among pregnant women – Chapter 5) and Children of Alcoholics (Chapter 4 1).

Burden of Suffering

The nomenclature for alcohol-related problems can be confusing. In the literature, the terms alcoholism, alcohol abuse, and severe alcohol dependency are clinical diagnoses by DSM-IIIR criteria and correspond to an ICD-10 classification. Alcohol consumption patterns (either excessive regular consumption or binge drinking) that put patients at high risk of physical, psychological or social consequences, are termed problem, hazardous, harmful, heavy, or excessive drinking, or mild to moderate alcohol dependency; no internationally-recognized criteria have been developed to classify problem drinking.

Severe alcohol dependency is present in 5-10% of the population, and problem drinking in 15-25%. In medical settings the rate of alcohol-related problems is even higher; routine screening with the instruments reviewed in this report have yielded prevalence rates of severe to mild dependency averaging 25% and as high as 36%.<13> Studies have repeatedly demonstrated that physicians fail to detect the majority of alcohol-related problems in their patients.

Maneuver

Case-finding

The two most extensively validated and commonly used standardized questionnaires are the Michigan Alcoholism Screening Test (MAST) and the four-question CAGE query. The MAST is a 25-item questionnaire that takes 20 minutes to administer; borderline alcoholism is identified by positive responses to at least four of the alcohol-related problem behaviors. Shorter versions of the MAST are generally used, and the instrument has shown sensitivities of 59-100% and specificities of 54-95%.

The CAGE is a mnemonic for the following questions: 1) ever felt the need to cut down on drinking? 2) ever felt annoyed by criticism of drinking? 3) ever had guilty feelings about drinking? 4) ever take a morning eye-opener drink? It can be easily incorporated into history-taking, and the presence of at least two positive responses in general medicine clinics has been shown to detect alcoholism with sensitivities ranging from 75%-89% and specificities from 68%-96%. Sensitivity and specificity are lower in populations where the prevalence of problem drinking is low,<14> or where problem drinking rather than severe alcohol dependency is the target.

Despite extensive validation, both the CAGE and the MAST have the limitations of being designed to detect severe alcohol dependency as opposed to problem drinking, and the questions are phrased in terms of lifetime occurrence, making it difficult to distinguish between current and previous problems. Neither instrument addresses "binge" drinking behavior, which has been found to be a more sensitive indicator of problem drinking in certain sub-groups such as women and inner-city populations.<15>

A promising screening questionnaire has recently been developed to address these issues. The Alcohol Use Disorders Identification Test (AUDIT, Table 1) is a 10-item questionnaire developed as part of a six-country World Health Organization (WHO) Collaborative Project on Identification and Management of Alcohol-Related Problems.<16> It is designed specifically to detect problem drinkers rather than alcoholics by placing emphasis on heavy drinking and frequency of intoxication rather than signs of dependency. The questions refer to lifetime alcohol experiences as well as those in the past year, thus distinguishing between current and previous problems. Its development in a broad range of cultures is thought to enhance cross-cultural validity, although further research is required to confirm this. In the WHO collaborative project, the sensitivity and specificity across the different countries were fairly consistent, averaging 80% and 98% respectively with a cut-off point of 10/40. It is currently being tested in various countries and sub-populations.

The reference criterion for problem drinking in the AUDIT is based on the expert judgement of the WHO Collaborative Project investigators, and this can reflect only the current knowledge and expert opinion since there are no internationally-recognized criteria to define hazardous drinking. Nonetheless, it appears to address criticisms of the CAGE and MAST effectively, and can be incorporated relatively easily into clinical practice. The yield of standardized instruments in clinical practice is still dependent on a neutral and sensitive approach by the clinician.

No biomarkers with adequate sensitivity or specificity for routine screening have yet emerged. Gamma-glutamyl transferase (GGT) continues to be used by researchers to identify excessive drinkers and to monitor the response to interventions; this, despite its poor sensitivity (40-52%) and specificity (78-89%). In a community sample of men one study found that the GGT was similar to the MAST for detecting problem drinkers, but the sensitivity of 50% is still inadequate for routine screening.<17> While not justified for detection, follow-up measures of GGT may be useful in patients attempting to reduce alcohol consumption. Researchers have also focused on the use of a combination of laboratory and clinical measurements to improve both sensitivity and specificity, but no consensus has emerged on what specific set of measures to use.

Counselling

There appears to be more acceptance in the alcohol treatment community of controlled drinking rather than abstinence as a treatment goal in problem drinkers.<18> Abstinence, however, continues to be the treatment goal in patients with severe alcohol dependency; these patients are generally not amenable to brief counselling interventions and should be referred for specialized treatment.

Effectiveness of Prevention and Treatment

In the Scandinavian population-based studies the intervention linked the elevated GGT to alcohol consumption; heavy drinkers were advised to reduce alcohol intake, and their progress was monitored regularly until the GGT levels normalized.<3,5> The Nilssen and colleagues study also evaluated the relative effectiveness of a second low-intensity intervention in which a more tenuous link was made between GGT levels and alcohol consumption, and subjects were given a pamphlet containing advice on GGT and alcohol consumption; no statistically significant differences were found between the two intervention groups at one-year follow-up. In the Kirstensen and coworkers study, the controls were informed by letter of their elevated GGT result and told to restrict alcohol, whereas no information was given to the controls in the Nilssen and colleagues study. This may account for the finding that in the Kirstensen and coworkers study, that GGT levels decreased significantly in both control and intervention groups, whereas in the Nilssen and colleagues study the statistically significant decrease in GGT levels and self-reported alcohol consumption was observed only in the intervention groups. The Kirstensen and coworkers study did, however, demonstrate a 61% reduction in hospital days and a 50% reduction in mortality in the intervention group after 5 years. The Kirstensen and coworkers study was limited to middle-aged males and a third of the subjects had symptoms of alcohol dependence. The Nilssen and colleagues study excluded alcoholics but included men and women aged 17-62 years; the effect by gender was stated to be homogenous. The limitation of both of these studies is the use of GGT as both a screening device and the principal outcome measure.

Two good quality primary care studies of adults aged 17-69 in the United Kingdom used comparable screening, intervention, and outcome measures.<6,7> Based on an independent two-stage screening procedure (self-administered health questionnaire, interviewer review of one-week drinking diary) patients were considered problem drinkers if males consumed more than 29 drinks per week or females more than 18 per week. Intervention subjects were referred to their general practitioner who gave the patient feedback about their consumption relative to national norms, advised them to reduce alcohol consumption to target levels of moderate drinking, and gave them a self-help pamphlet. Follow-up at one-year demonstrated that in the Wallace and associates study 45% of the intervention group reduced their drinking to target levels compared to 25% in the controls;<6> in the Anderson & Scott study the proportions were 18% and 5% respectively.<7> In the Wallace and associates study, intervention subjects were encouraged to return for at least one and up to 4 monitoring visits during the year and the study population included very heavy drinkers; these may account for the greater reductions in excessive drinking. The authors found that although the intervention was also effective in women, their reductions in reported consumption were not accompanied by reductions in mean GGT levels; the results for women were not reported in the Anderson & Scott study.

The early intervention study of the WHO Collaborative Project on Identification and Management of Alcohol-Related Problems did not use the AUDIT to identify problem drinkers because it was not completed by the initiation of the trial. Instead it used a general health and lifestyle questionnaire and a structures assessment interview to identify problem drinkers.<11> Based on the criteria of ³2 intoxications/month or 29 drinks/week for men and 19 drinks/week for women, 1,559 problem drinkers aged 19-70 years in eight countries (Australia, the United Kingdom, Norway, Mexico, Kenya, the former Soviet Union, Zimbabwe, and the United States) were randomly assigned to either control, simple advice or brief counselling groups. After a 9-month average follow-up in 75% of the patients drinking behavior based on self-report was reduced in all groups, males in both intervention groups showed a significantly greater reduction in typical daily consumption and drinking intensity on the basis of self-report than did the controls. The intervention effect in the much smaller number of women was not statistically significant. There was no statistically significant difference between the simple advice and brief counselling intervention groups.

The results of these studies support the effectiveness of routine identification of problem drinkers and advice to reduce alcohol consumption, although in only one study<3> was the reduction corroborated by decreased morbidity and mortality over a longer period. None of the studies used the standardized screening instruments which have been reviewed in this report. Simple advice was found to be as effective as a brief counselling intervention.<5,11> Several authors suggested that the observed improvement in controls might be attributable to a therapeutic effect of the screening procedure itself. It is not clear whether the results can be generalized to the elderly. The effectiveness in these trials was less pronounced in women,<6,8,11> but a randomized trial of problem drinkers’ responsiveness to different interventions showed that women were more likely to achieve problem-free moderate drinking than men.<19>

Recommendations of Others

The Alcohol Risk Assessment and Intervention (ARAI) Project of the College of Family Physicians of Canada recommends that all patients age 12 years or older be screened to assess their level of risk drinking, and that patients who drink at potentially problematic or problematic levels be counselled and followed-up to reduce their drinking; and that patients with severe problems be referred to appropriate specialized treatment with periodic follow-up by the primary care physician. The project provides aids for both physicians and patients.

The Institute of Medicine in the United States recommends that all patients be screened for alcohol problems. If mild or moderate problems are detected, a brief counselling intervention should be provided and the patient be periodically monitored. If a severe problem is detected, the patient should be referred for specialized treatment.

Conclusions and Recommendations

Unanswered Questions (Research Agenda)

Evidence

This review was initiated in August 1993 and the

recommendations were approved by the Task force in March 1994.

Acknowledgements

Table 1: Alcohol Use Disorders Identification Test (AUDIT)
 

Scoring1:  0 1 2 3 4 How often do you have a drink containing alcohol?  Never Monthly or less Two to four times a month Two to three times a week Four or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking?  1 or 2 3 or 4 5 or 6 7 to 9 10 or more How often do you have six or more drinks on one occasion?  Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you found that you were not able to stop drinking once you had started?  Never Less than monthly Monthly  Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected from you because of drinking?  Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking?  Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because you had been drinking?  Never Less than monthly Monthly Weekly Daily or almost daily Have you or someone else been injured as a result of your drinking? No Yes, but not in the last year Yes, during the last year Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?  No Yes, but not in the last year Yes, during the last year

¹Cut-off point of 10/40 indicates problem drinking.

 Full Citation

• Haggerty JL. Early detection and counselling of problem drinking. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 488-98.

Link to Structured Abstract of this review

Link to Summary Table of this review

Link to Selected References list of this review

Top of Page

CTFPHC Home Page

Reprinted in modified format by the Canadian Task Force on Preventive Health Care
with permission.
For any technical issues please contact: webmaster@ctfphc.org
Original Copyright © 1994 Minister of Supply and Services Canada.
Last modified March 27, 1998.