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Assessing alcohol problems

Classifying alcohol use

Alcohol use may be classified as:

  • low risk
  • at risk
  • mild, moderate and severe alcohol use disorder.

Low-risk drinking

Moderate alcohol consumption lowers cardiovascular mortality by elevating cardio-protective lipids and inhibiting platelet aggregation. Most of these benefits can be obtained by consuming less than one drink per day. More than two drinks per day for women and three for men increases mortality and morbidity.

Download an infographic developed by the Canadian Centre on Substance Abuse (CCSA) that illustrates the relationship between chronic illness and alcohol consumption.

A lower level of alcohol consumption is recommended for women because they reach a higher blood alcohol level and have more health consequences than men for the same rate of consumption (Stokkeland et al., 2008).

The Canadian low-risk drinking guidelines (CCSA, 2018) define low-risk drinking as:

  • weekly intake of alcohol for men that does not exceed 15 standard drinks, with no more than three drinks a day most days
  • weekly intake of alcohol for women that does not exceed 10 standard drinks, with no more than two drinks a day most days
  • daily consumption that does not exceed four standard drinks for men and three for women on any single occasion.

Abstinence is recommended for patients who:

  • are pregnant
  • use medications that may interact dangerously with alcohol
  • have medical conditions that may be worsened by alcohol (e.g., seizure disorder, cirrhosis, active ulcer)
  • have a past history of more severe alcohol use disorder.

At-risk drinking

At-risk drinking involves drinking that exceeds the low-risk drinking guidelines but does not meet criteria for an alcohol use disorder. This level of drinking puts the person at a higher risk of developing alcohol-related medical, psychological or social problems.

Alcohol use disorder

The Diagnostic and Statistical Manual of Mental Disorders ([DSM-5], American Psychiatric Association, 2013) defines alcohol use disorder as clinically significant impairment or distress caused by alcohol use.

The DSM-5 alcohol use disorder diagnosis replaces the DSM-IV diagnoses of alcohol abuse and alcohol dependence. A DSM fact sheet developed by the U.S. National Institute on Alcohol Abuse and Alcoholism explains other changes in diagnosing alcohol use problems. 

Differentiating between at-risk drinking and alcohol use disorder

At-risk drinking refers to consumption above the low-risk guidelines.

Alcohol use disorder involves clinically significant impairment or distress caused by alcohol use. It can be mild, moderate or severe.

Indicators of at-risk drinking versus alcohol use disorder

Assessment tools

The Alcohol Use Disorders Identification Test  (manual and questionnaire) is a useful 10-item survey that patients can fill out in the waiting room or during a face-to-face interview. It was developed initially as a screening test, but can be used to gather more information about alcohol use.

The AUDIT asks how much the person drinks and whether they have experienced negative consequences of drinking. When scored, the AUDIT helps to differentiate at-risk drinking from alcohol use disorder.

A cut-off score of 8 or more indicates unhealthy drinking. Newer research suggests that the cut-off score be lower for women (Johnson et al., 2013; Levola & Aalto, 2015; Neuman et al., 2004). A score higher than 15 indicates a more severe alcohol use disorder.

Matching AUDIT score to intervention

The Alcohol Use Assessment form can be used to take a history of alcohol use and collect other essential information, such as other drug use and drinking and driving. The form can also be used to record the results of physical examinations and laboratory tests.

Level-appropriate interventions for alcohol use

Most people who use alcohol do so at a low-risk or at-risk level. However, 21 per cent of people who drink exceed the guidelines for chronic harm and 15 per cent exceed the guidelines for acute harm (Statistics Canada, 2013). About 2.5 per cent have a moderate or severe alcohol use disorder.

Interventions should match the category of drinking

Patients with more severe alcohol use disorder need more intensive interventions. These include ongoing counselling, medications (naltrexone and acamprosate) and connections to other treatment programs. These patients do as well when treated in primary care settings as in specialized care (Miller et al., 2011; O'Malley et al., 2003). Screening and brief interventions delivered by primary care providers are very effective at reducing drinking in patients with at-risk drinking and mild alcohol use disorder (Bertholet et al., 2005).