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Alcohol problems: Screening and referral

Key points

  • Include questions about alcohol use as part of routine lifestyle discussions with all clients.
  • Components of screening include general screening questions, an alcohol consumption history, screening tools and laboratory tests.
  • Suicide risk increases when a person has alcohol problems.

Who should be screened?

  • In primary care settings, incorporate questions about alcohol use into routine lifestyle questions for all clients.
  • In mental health settings, incorporate questions about alcohol consumption into initial screening and assessment.

Screening protocols

Alcohol consumption history

  • Ask all adolescent (age 12+) and adult clients at baseline, annual physical.
  • Ask for a specific weekly consumption rate.
  • Convert the client's response into standard drinks: for example, 12 oz. of beer, 5 oz. of wine or 1½ oz. of spirits.
  • Ask about the client's maximum alcohol consumption on one day in the past one to three months.

Screening questions

Males: "How many times in the past year have you had five or more drinks in a day?"

Females: "How many times in the past year have you had four or more drinks in a day?"

  • Replying "more than once" to these questions indicates a positive screen for problem drinking.
  • Depending on the prevalence of alcohol problems you see in your clinic, this test may generate quite a few false positives. For example, a person who has had only two episodes of heavy drinking in the past year is unlikely to have a significant alcohol problem.
  • Clients who screen positive should be fully assessed before you diagnose an alcohol use disorder.

Screening tools

CAGE

  • best used as a waiting room questionnaire, but can be incorporated into a clinical interview
  • 70–80% sensitivity in primary care for detecting alcohol problems
  • screen positives require further assessment.

Download the CAGE questionnaire [pdf].

Laboratory measures

Use laboratory tests to confirm clinical suspicion and monitor the client's response to treatment.

GGT

  • 5–50% sensitivity in detecting 4+ drinks per day
  • half-life of four weeks
  • elevated by hepatic enzyme inducers (e.g., phenytoin), diabetes, obesity, etc.

MCV

  • somewhat less sensitive than GGT
  • at least three months to return to baseline
  • elevated by medications, folic acid and B12 deficiency, liver disease, hypothyroidism, etc.

Risk assessment

  • 15–25% of people who die by suicide have experienced substance use problems.
  • An increased risk of suicide in a person with alcohol dependence correlates with:
    • active substance use
    • adolescence
    • second or third decade of illness
    • co-occurring mental health problems
    • recent or anticipated interpersonal loss.
  • Substance use may be a person's attempt to blunt the anxiety or mood disturbance associated with a co-occurring mental health problem.

Specialist referral

Consider making a referral for specialist treatment if your client has experienced one or more of the following:

  • shows signs of moderate or severe alcohol dependence
  • has failed to benefit from structured brief advice and an extended brief intervention and wants further help for an alcohol problem
  • shows signs of severe alcohol-related impairment or has a related comorbid condition (e.g., liver disease or alcohol-related mental health problems).

When you are making a referral, the referral agent will ask you to outline the problem the client is experiencing and any constraints the client faces (e.g., mobility, geography). The agent will then let you know what services are available.

In Ontario, call the Drug and Alcohol Helpline (ConnexOntario) at 1 800 565-8603 anytime to speak to a referral agent. The helpline also has a comprehensive online database of substance use treatment programs and services.

Referral agents can also provide information about local mutual aid groups, such as Alcoholics Anonymous.

Evidence summary

Kahan, M. & Watts, K. (Eds.). (2010). Dealing with alcohol problems. In Primary Care Addiction Toolkit. Toronto, ON: Centre for Addiction and Mental Health.

National Institute for Health and Clinical Excellence. (2011). Alcohol-Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence (Clinical Guideline 115). London, UK: Author.


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It's worth looking at the Quick Reference Guide that goes with the NICE guideline (http://guidance.nice.org.uk/CG115/QuickRefGuide/pdf/English)
They also have a publication for clients and families.
Posted on 31/01/14 7:36 PM.
Having to convert to standard drinks seems a real barrier both in screening and assessment
Posted on 31/01/14 10:09 PM.
Is there an easier solution? We need a way to track and compare beer, wine and spirits.
Posted on 03/02/14 12:18 AM.