Audit Romania Alcool

7/30/2019 Audit Romania Alcool

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ThomasF. BaborJohn C. Higgins-Biddle

John B. SaundersMaristelaG. Monteiro

World Health Organ izat ion

A U D I T

TheAlcoholUseDisordersIdentificationTest

GuidelinesforUseinPrimaryCare

S e c o n d E d i t i o n

WHO/MSD/MSB/01.6a

Original: English

Distribution: General

Department of Men tal Health and Substance Dependence


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Department of Me ntal Health and Substance Dependence

ThomasF. Babor

John C. Higgins-Biddle

John B. SaundersMaristelaG. Monteiro

World Health Organ izat ion

A U D I T

TheAlcoholUseDisorders

IdentificationTest

GuidelinesforUseinPrimaryCare

S e c o n d E d i t i o n

WHO/MSD/MSB/01.6a

Original: EnglishDistribution: General


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2 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATIONTEST

Abstract

Th is manualintroduces the AUDIT, the A lcohol Use DisordersIdentificat ion Test, and describes how to

use it to identify persons w ith hazardous and harmful patterns of alcoholconsumption . The AUDIT was

developed by the World Health Organization (WH O) as a simp le method of screening for excessive drink ing

and to assist in brief assessment.It can help in identifying excessive drink ing as the cause of the presenting

illness.It also provides a framework for intervent ion to help hazardous and harmful drinkers reduce or ceasealcoholconsumption and thereby avoid the harmfulconsequences of their drink ing . The first ed ition of this

manual was published in 1989 (Document No. WHO/MNH/DAT/89 .4) and wassubsequently updated in

1992 (WHO/PSA/92 .4).Since that time it has en joyed w idespread use by both hea lth workers and alcohol

researchers. W ith the grow ing use of alcoholscreen ing and the international popularity of the AUDIT,

there was a need to revise the manual to take into account advances in research and clinical experience.

This manualis written primar ily for health care practitioners, but other professionals who encounter persons

w ith alcohol-related problems may also find it useful.It is designed to be used in con junction w ith a

companion document that providescomplementary information about early intervention procedures, entitled

Brief Intervention for Hazardous and Harmful Drink ing: A Manual for Use in Primary Care . Together

these manuals describe a comprehensive approach to screening and brief intervention for alcohol-related

problems in primary health care .

Acknowledgements

The revision and f ina lisat ion of this document were coordinated by Mariste la Monteiro w ith techn ical

assistance from Vlad imir Poznyak from the WHO Department of Menta l Health and Substance Dependence,

and Deborah Talam ini, Un iversity of Connecticut .Financialsupport for th is publicat ion was provided by

the M inistry of Health and We lfare of Japan.

World Health Organiza tion 2001

Th is document is not a formal publicat ion of the World Health Organization (WHO), and all rights are

reserved by the Organ iza tion . The document may, however, be freely reviewed, abstracted, reproduced ,

and translated, in part or in whole but not for sale or for use in con junction w ith commercial purposes.

Inquiriesshould be addressed to the Department of Menta l Health and Substance Dependence, World

Health Organization , CH-1211 Geneva 27,Sw itzerland, which w ill be glad to provide the latest information

on any changes made to the text, plans for new editions and the reprints, reg ional adaptations and trans-

lat ions that are already availab le.

Authors alone are responsible for views expressed in th is document, which are not necessarily those of

the World Health Organiza tion .


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TABLEOFCONTENTSI 3

TableofContents

Purpose of this Manual

W hy Screen for Alcohol Use?

The Cont ext of Alcohol Screening

Development and Validation of the AUDIT

Administration Guidelines

Scoring and Interpretation

How to Help Pat ients

Programme Implementat ion

Appendix

A . Research Guidelines for the AUDIT

B. Suggested Format for AUDIT Self-Report Quest ionnaire

C. Translat ion and A daptat ion to Specif icLanguages,Cultures and Standards

D . Clinical Screening Procedures

E. Training Materials for AUDIT

References

4

5

8

10

14

19

21

25

28

30

32

33

34

35


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This manual introduces the AUDIT, the

A lcohol Use DisordersIdentificat ion

Test, and describes how to use it to identify

persons w ith hazardous and harmful pat-

terns of alcoholconsumption . The AUDIT

was developed by the World Health

Organiza tion (WHO) as a simp le method

of screening for excessive drink ing and to

assist in brief assessment.1,2 It can help

identify excessive drinking as the cause

of the presenting il lness. It provides

a framework for intervention to help risky

drinkers reduce or cease alcoho lcon-

sumption and thereby avoid the harmful

consequences of their drink ing . The AUDIT

also helps to identify alcoho l dependence

and some specificconsequences of harm-

fu l drinking.It is particularly designed for

healthcare pra

ctitioners and a range of

health set tings, but w ith suitable instruc-

tionsit can be self-administered or used

by non-health professiona ls.

To this end , the manual w il l describe:

Reasons to ask about alcohol

consumption

The context of alcoho lscreening

Development and validation of

the AUDIT

The AUDIT questions and how

to use them

Scoring and interpretation

How to conduct a clinicalscreening

exam ination

How to help patients who screen positive

How to imp lement a screening

programme

PurposeofthisManual

The appendices to this manualcontain

additiona l informat ion useful to practi-

tioners and researchers. Further research

on the reliab il ity, va lidity, and imp lemen-

ta tion of screening w ith the AUDIT is

suggested using guide lines out lined in

Appendix A . Appendix B contains an

example of the AUDIT in a self-report

questionna ire format. Appendix C pro-

vides gu ide lines for the translat ion and

adaptat ion of the AUDIT. Appendix D

describesclinicalscreening procedures

using a physical exam, laboratory tests

and medical history data. Appendix E lists

informat ion about available training

materials.



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There are many forms of excessive

drink ing that cause substantial risk or

harm to the individua l. They include high

leve l drink ing each day, repeated

ep isodes of drinking to intoxicat ion,

drinking that is actua lly causing physical

or mental harm, and drinking that has

resulted in the person becoming depen-

dent or addicted to alcohol. Excessive

drinking causesil lness and distress to the

drinker and his or her family and friends.

It is a ma jor cause of breakdow n in rela-

tionships, trauma, hospitaliza tion , pro-

longed disab il ity and early death.

A lcoho l-related problems represent an

immense economic loss to many commu-

nities around the world.

AUDIT was deve loped to s

creen for

excessive drink ing and in particular to

he lp practitioners identify people who

wou ld benefit from reducing or ceasing

drinking . The majority of excessive

drinkers are undiagnosed . Often they

present w ith symptoms or problems that

wou ld not normally be linked to their

drinking . The AUDIT w il l he lp the practi-

tioner identify whether the person has

hazardous(or risky) drink ing , harmfuldrinking , or alcoho l dependence.

Hazardous drinking3 is a pattern of alco-

ho lconsumption that increases the risk

of harmfulconsequences for the user or

others. Hazardous drinking patterns are

of public health significance despite the

absence of any current disorder in the

ind

iv

idua

lus

er.

Harmful userefers to alcoholconsump-

tion that results in consequences to phys-

ical and mental hea lth .Some would also

consider socialconsequences among the

harmscaused by alcoho l3, 4.

A lcohol dependence is a cluster of

behavioura l,cognitive , and physiolog ical

phenomena that may develop after

repeated alcohol use4. Typ ically, these

phenomena include a strong desire to

consume alcoho l, impaired control over

its use, persistent drinking despite harm-

fu lconsequences, a higher priority given

to drink ing than to other activities and

ob ligations, increased alcoho l to lerance,

and a physical w ithdrawal reaction when

alcohol use is discontinued.

A lcoholisimp licated in a w ide variety of

diseases, disorders, and injuries, as well as

many social and legal problems5,6,7.It is a

ma jor cause of cancer of the mouth,

esophagus, and larynx.Liver cirrhosis and

pancreatitis often result from long-term,

excessive consumption . A lcoholcauses

harm to fetuses in women who are preg-

nant. Moreover, much more common

medicalconditions,such as hypertension ,

gastritis,diabetes, and some forms of

stroke are like ly to be aggravated even by

occasionaland short-term alcoho lcon-

sumption , as are mental disorderssuch as

depression. Automobile and pedestrian

injuries, falls, and work-related harm fre-

quently result from excessive alcoholcon-

sumption . The risks related to alcohol are

linked to the patt ern of dr

ink

ing and theamount of consumption5. While persons

w ith alcohol

WHYSCREENFORALCOHOLUSE?I 5

WhyScreenforAlcoholUse?


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dependence are most like ly to incur high

leve ls of harm, the bulk of harm associat-

ed with alcohol occurs among people who

are not dependent , if only because there

are so many of them8. Therefore , the

identification of drinkers w ith various

types and degrees of at-risk alcoholcon-

sumption has great potential to reduce all

types of alcoho l-related harm.

Figure 1 il lustrates the large variety of

health problems associated w ith alcoho l

use. A lthough many of these medical

consequences tend to be concentrated in

persons w ith severe alcohol dependence,

even the use of alcohol in the range of

20-40 grams of absolute alcoho l per day

is a risk factor for acc idents, injuries, and

many soc

ial problems5, 6

.

Many factorscontribute to the develop-

ment of alcoho l-related problems.

Ignorance of drinking limits and of the

risks associated w ith excessive alcoho l

consumption are major factors. Social

and environmentalinf luences,such as

customsand attitudes that favor heavy

drinking , also play important roles. Of

utmost importance for screening , however,

is the fact that people who are not

dependent on alcohol may stop or

reduce their alcoholconsumption w ith

appropriate assistance and effort. Once

dependence hasdeveloped,cessat ion

of alcoholconsumption is more diff icult

and often requ iresspecialized treatment.

A lthough not all hazardous drinkers

become dependent

,

no one develop

s

alcoho l dependence w ithout having

engaged for some time

in hazardous alcoho l use. G iven these

factors, the need for screening becomes

apparent .

Screening for alcoho lconsumption

among patien ts in primary care carries

many potential benefits.It provides an

opportunity to educate patien ts about

low-risk consumption levels and the risks

of excessive alcoho l use.Informat ion

about the amount and frequency of alco-

ho lconsumption may inform the d iagno-

sis of the patients presenting cond ition ,

and it may alert clinicians to the need to

advise patients whose alcoho lconsump-

tion might adversely affect their use of

medications and other aspects of their

treatment .Screening also offers the

opportunity for practitioners to take pre-

ventative measures that have proven

effective in reducing alcohol-re lated risks.



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WHYSCREENFORALCOHOLUSE?I 7

Figure 1

EffectsofHigh-RiskDrink ing

Numb, ting ling toes.Painful nerves.

Impaired sensat ionleading to falls.

Inf lammation of the pancreas.

Vitamin deficiency. Bleeding .Severe inf lammation

of the stomach. Vom iting .

Diarrhea. Malnutrition .

Cancer of throat and mouth .Premature aging . Drinker's nose.

Weakness of heart muscle.Heart failure . Anemia.

Impaired blood clotting .Breast cancer.

In men:Impaired sexual performance.

In women:

Risk of giving birth to deformed ,retarded babies or low birthweight babies.

Aggressive ,irrational behaviour.Arguments. Violence.Depression . Nervousness.

Frequent colds.Reducedresistance t o infection .Increased risk of pneumonia.

A lcohol dependence.Memory loss.

Ulcer.

Liver damage.

Trembling hands.Ting ling fingers.Numbness.Painful nerves.

High-risk drink ing may lead to social, lega l, medical, domestic, job and financial

problems. It may also cut your lifespan and lead to acc idents and death from drunk-

en driving .


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TheContextofAlcoholScreening


While th is manual focuses on using the

AUD IT to screen for alcoholcon-

sumption and related risks in primary care

medicalset tings, the AUDIT can be effec-

tive ly applied in many other contexts as

well .In many cases procedures have

already been developed and used in these

set tings. Box 1 summarizes informat ion

about the sett ings, screening personnel,

and target groupsconsidered appropriatefor a screening programme using the AUDIT.

Murray9 has argued that screening might

be conducted profitably w ith :

general hosp ital patients, especially those

w ith disorders known to be associated

w ith alcohol dependence (e.g., pancre-

at itis,cirrhosis, gastritis, tuberculosis,

neurolog ical disorders, card iomyopathy);

persons who are depressed or who

attempt suicide;

other psychiatric pat ients;

patients attend ing casua lty and emer-

gency services;

patients attend ing general practitioners;

vagrants;

prisoners; and

those cited for legal offencesconnected

w ith drink ing (e.g., driving while intoxi-

cated, public intoxicat ion).

To these shou ld be added groupsconsid-

ered by a WHO Expert Comm ittee7 to be

at high risk of develop ing alcoho l-related

prob lems: m idd le-aged ma les, ado lescents,

migrant workers, and certa in occupation-

al groups(such as business execut ives,

enterta iners,sex workers, pub licans, and

seamen). The nature of the risk differs by

age, gender, dr inking context, and drinking

pattern, w ith sociocultural factors playingan important role in the definition and

expression of alcoho l-related problems6.


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THECONTEXTOFALCOHOLSCREENINGI 9

Box 1

Personnel, SettingsandGroupsConsideredAppropriateforaScreeningProgrammeUsingtheAUDIT

Sett ing TargetGroup Screen ingPersonnel

Primary care clinic Med ical patients Nurse,social worker

Emergency room Acc ident victims, Physician , nurse, or staff

Intoxicated patien ts,

trauma victims

PhysiciansRoom Medical patients General practitioner,

Surgery family physician or staff

General Hospita l wards Patients w ith Internist,staff

Out-patient clinic hypertension, heart

disease, gatrointestina lor neurological disorders

Psychiatric hospita l Psychiatric pa tients, Psychiatrist,staff

particularly those

who are suicida l

Court, jail , prison DWI offenders Off icers, Counsellors

violent criminals

Other health-related Persons demonstrating Health and human

facil ities impaired social or service workers

occupational function ing

(e.g. marita l discord ,

child neglect, etc.)

M il itary Services En listed men and officers Med ics

Work place Workers, especially those Employee assistance staff

Employee assistance having problems w ith

Programme productivity, absenteeism

or acc idents


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10 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATION TEST

Developmentand

ValidationoftheAUDIT

The AUDIT was developed and evaluat-

ed over a period of two decades, and

it has been found to provide an accurate

measure of risk across gender, age, and

cultures1, 2,10 . Box 2 describes the conceptu-

al doma ins and item content of the AUDIT,

which consists of 10 questions about

recent alcohol use, alcohol dependence

symptoms, and alcohol-related problems.

As the first screening test designed specif-ically for use in primary care set tings, the

AUD IT has the follow ing advantages:

Cross-nationa lstandardiza tion: the

AUD IT was va lidated on primary health

care patients in six countries1,2.It is the

on ly screening test specifically designed

for internationa l use;

Identifies hazardous and harmful alco-

ho l use, as well as possible dependence;

Brief , rapid, and flexible;

Designed for primary health care workers;

Consistent w ith ICD-10 definitions of alco-

ho l dependence and harmful alcohol use3,4;

Focuses on recent alcoho l use.

In 1982 the World Health Organizat ion

asked an internationa l group of investiga-

tors to develop a simp le screening instru-ment2.Its purpose was to identify persons

w ith early alcohol problems using proce-

dures that were su itab le for health systems

in both develop ing and developed countries.

The investigators rev iewed a variety of

self-report, laboratory, and clinical proce-

dures that had been used for th is purpose

in d ifferent countries. They then in it iated a

cross-nationalstudy to select the best fea-

tures of these various nat ional approaches

to screening1.

Th iscomparat ive field study wasconducte d

in six countries(Norway, Austra lia, Kenya,

Bu lgaria, Mexico, and the United States

of America).

The method consisted of selecting items

that best disting uished low-risk drinkers

from those w ith harmful drinking. Unlike

previousscreening tests, the new instrument

wasintended for the early identificat ion ofhazardous and harmful drinking as well as

alcohol dependence (alcoholism). Nearly

2000 patien ts were recru ited from a variety

of health care facilities,including specialized

alcohol treatment centers.Sixty-four percen t

were current drinkers, 25% of whom were

diagnosed as alcohol dependent.

Parti

cipants were given a physi

cal exam i-nation , includ ing a b lood test for standard

blood markers of alcoholism, as well as an

extensive interview assessing demographic

characteristics, medical history, hea lth

complaints, use of alcohol and drugs, psy-

cho log ical reactions to alcohol, problems

associated w ith drinking , and family histo-

ry of alcohol problems. Items were select-

ed for the AUDIT from this pool of ques-

tions primarily on the basis of correlat ionsw ith daily alcohol intake, frequency of

consum ing six or more drinks per drink ing

ep isode, and their ab il ity to discriminate

hazardous and harmful drinkers.Items were

also chosen on the basis of face va lidity,

clin ica l re levance, and coverage of re levant

conceptua l domains(i.e ., alcoho l use, alco-

ho l dependence, and adverse consequences

of drinking ).Fina lly,special attention in item

selection was g iven to gender appropriate-

ness and cross-nat ional genera lizab ili ty.


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Once the AUDIT had been pub lished , the

deve lopers recommended additional va li-

da tion research .In response to th is request,

a large number of stud ies have been con-

ducted to evaluate its va lidity and reliab il-

ity in different clinical and community

samples throughout the world10 . At the

recommended cut-off of 8, most studies

have found very favorab le sensitivity and

usually lower, but stil l acceptable,speci-

ficity, for current ICD-10 alcohol use dis-

orders10 ,11 ,12 as well as the risk of future

harm12 . Nevertheless, improvements in

detection have been achieved in some

cases by lowering or raising the cut-off

score by one or two po ints, depend ing

on the popu lat ion and the purpose of

the screening programme11 ,12 .

A variety of subpopulat ions have been stud-

ied,including primary care patien ts13 , 14 , 15 ,

emergency room cases11 , drug users16 ,

the unemployed17 , university students18 ,

elderly hospita l pat ien ts19 , and persons of

low socio-economicstatus20 . The AUDIT

has been foun d to provide good d iscrim i-

nat ion in a variety of sett ings where these

populat ions are encountered . A recent

systematic review21 of the literature has

concluded that the AUDIT is the best

screening instrument for the who le range

of alcoho l problems in primary care , as

compared to other questionnairessuch as

the CA GE and the MAST.

Cultural appropriateness and cross-

nationa lapp licab ili ty were important con-

siderat

ion

s

in the deve

lopment of theAUD IT1, 2.Research has been conducted

in a w ide variety of countries and

cultures11 , 12 , 13 , 15 , 19 , 22 , 23 , 24 ,suggesting

that the AUDIT has fu lfil led its prom ise as

an internat iona lscreening test.

A lthough evide nce on women issomewhat

limited11 , 12 , 24 , the AUDIT seems equa lly

appropriate for males and females. The

effect of age has not been systematically

analyzed as a possible influence on the

AUDIT, but one study19 found low sensi-

tivity but h igh specificity in patients above

age 65. The AUDIT has proven to be

accurate in detecting alcohol dependence

in un iversity students18 .

In comparison to other screening tests,

the AUDIT has been found to perform

equa lly we ll or at a h igher degree of accu-

racy10 , 11 , 25 , 26

across a w ide variety of cri-terion measures. Bohn , et al.27 found a

strong correlat ion between the AUDIT

and the MAST (r= .88) for both males and

females, and corre lat ions of .47 and .46

for males and females, respective ly, on a

covert content alcoholism screening test.

A high correlation coefficien t (.78) was

also found between the AUDIT and the

CAGE in ambulatory care patients26 .

AUDIT scores were found to corre late we llw ith measures of drink ing consequences,

at titudes toward drink ing , vu lnerabil ity to

alcoho l dependence , negat ive mood states

after drinking , and reasons for drink ing27 .

It appears that the totalscore on the AUDIT

reflects the extent of a lcoholinvo lvement

along a broad continuum of severity.

Two studies haveconsidered the re lat ionbetween AUDIT scores and future ind ica-

tors of a lcoho l-re lated prob lems and more



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globallife functioning.In one study17 ,the

like lihood of remaining unemployed over

a two year period was 1.6 times higher

for ind ividua ls w ith scores of 8 or more

on the AUDIT than for comparable per-

sons w ith lower scores.In another study28 ,

AUD IT scores of ambulatory care patients

predicted future occurrence of a physical

disorder, as well associal problems relat-

ed to drink ing. AUDIT scores also predict-

ed health care util iza tion and future risk

of engaging in hazardous drinking28 .

Severalstudies have reported on the reli-

ab il ity of the AUDIT18 , 26 , 29 . The results

ind icate h igh internalconsiste ncy,suggest-

ing that the AUD IT is measur ing a sing le

construct in a reliab le fash ion . A test-retest

reliab il ity study29

ind icated high reliab il ity(r= .86) in a samp le consisting of non-haz-

ardous drinkers, cocaine abusers, and

alcoho lics. Another methodolog icalstudy

wasconducted in part to investigate the

effect of question ordering and wording

changes on prevalence estimates and

internalconsistency reliab il ity22 . Changes

in question ordering and wording did not

affect the AUDIT scores,suggesting that

w ith in limits, researcherscan exercisesome flexibil ity in modifying the order

and wording of the AUDIT items.

W ith increasing evidence of the reliabil ity

and validity of the AUDIT,studies have

been conducted using the test as a

prevalence measure .Lapham, et al.23

used it to estimate prevalence of alcoho l

use disorders in emergency rooms(ERs)of three regiona l hospitals in Thailand.

It wasconcluded that the ER is an idea l

set ting for imp lementing a lcoho lscreen-

ing w ith the AUDIT.Similarly,Picc inell i, et

al.15 evaluated the AUDIT as a screen ing

to o l for hazardous alcoho l intake in pr ima-

ry care clinics in Ita ly. AUDIT performed

well in ident ify ing alcoho l-re lated d isorders

as well as hazardous use.Ivis, et al.22

incorporated the A UDIT into a general

population telephone survey in Ontario,

Canada.

Since the AUDIT Users Manual was first

published in 198930 , the test has fulfil led

many of the expecta tions that inspired its

development.Its re liab ility and valid ity have

been esta b lishe d in research conducted in

a variety of sett ings and in many different

na tions. It has been translated into many

languages, includ ing Turk ish , Greek, H ind i,

German, Dutch,Polish,Japanese,French,

Portuguese,Spanish, Dan ish,Flem ish,

Bu lgarian , Chinese,Ita lian , and Nigerian

dialects. Tra ining programmes have been

deve loped to facili tate its use by physicians

and other health care providers31 , 32 (see

Appendix E).It has been used in primary

care research and in ep idemiological

studies for the estimation of prevalencein the general population as well asspe-

cific institut ional groups(e.g., hospita l

pa tients, primary care patients). Despite

the high level of research activity on the

AUDIT, further research is needed , espe-

cially in the less developed countries.

Appendix A provides guide lines for con-

tinued research on the AUDIT.

DEVELOPMENTANDVALIDATIONOFTHEAUDIT I 13


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AdministrationGuidelines

The AUDIT can be used in a variety of

ways to assess pa tien ts alcoho l use,

but programmes to imp lement it should

first set guide lines that consider the

patient scircumstances and capacities.

Add itionally,care must be taken to tell

patients why questions about alcoho l use

are being asked and to provide informa-

tion they need to make appropriate

responses. A decision must be madewhether to administer the AUDIT orally or

as a wr itten,self-report questionnaire.

Fina lly,consideration must be g iven to

using skip-outs to shorten the screening

for greater efficiency. Th issection recom-

mends gu ide lines on such issues of

administration.

ConsideringthePat ientA ll patientsshould be screened for alco-

ho l use, preferably annually. The AUDIT

can be administered separate ly or com-

bined w ith other questions as part of a

general health interview, a lifestyle ques-

tionnaire, or medical history.If health

workersscreen only those they consider

most like ly to have a drink ing problem ,

the majority of patients who drink exces-sive ly w il l be missed . However, it is impor-

tant to consider the condition of the

patients when asking them to answer

questions about alcoho l use. To increase

the patients receptivity to the questions

and the accuracy of respond ing , it is

important that:

The interviewer (or presenter of the sur-

vey) be friendly and non-threatening;

The patient is not intoxicated or in need

of emergency care at the time;

The purpose of the screening be clearly

stated in terms of its relevance to the

patients health status;

The information patients need to

understand the questions and respond

accurately be provided; and

Assurance is given that the patientsresponses w il l remain confidential.

Health workersshould try to establish

these conditions before the AUDIT is

given. When these cond itions are not pre-

sent or when a patient is resistant, the

C linicalScreening Procedures(discussed in

Appendix D) may provide an alternative

course of action .

Choose the best possible circumstance for

administering the AUDIT.For patients

requiring emergency treatment or in great

pa in, it is best to wait until their medical

condition hasstabil ized and they have

become accustomed to the health set ting

where administration of the AUDIT is to

take place.Look for signs of alcoho l or

drug intoxicat ion .Pat ien ts who have alco-

ho l on their breath or who appear intoxi-cated may be unre liable respondents.

Consider screening at a later time .If this

is not possible, make note of these find-

ings on the patient's record .

When presented in a medicalcontext

w ith genuine concern for the pat ien ts

well be ing, patients are almost always

open and responsive to the AUDIT ques-

tions. Moreover, most patients answer the

questions honestly. Even when excessive


16/41

ADMINISTRATIONGUIDELINESI 15

drinkers underestimate their consump-

tion , they often qualify on the AUDIT

scoring system as positive for alcohol risk.

IntroducingtheAUDIT

Whether the AUDIT is used as an oral

interview or a written questionnaire, it is

recommended that an explanation be

given to patients of the content of thequestions, the purpose for asking them,

and the need for accurate answers. The

fo llow ing are il lustrative introductions for

ora l delivery and written questionnaires:

No w I am going to ask yousome ques-

tions about your use of alcoholic bever-

ages during the past year. Because alco-

hol usecan affect many areas of health

(and mayinterfere with certain medica-

tions), it is important for us to know how

much you usually drink and whether you

have experienced any problems with your

drinking.Please try to be as honest and

as accurate as youcan be.

As part of our healthservice it is impor-

tant to examine lifestyle issues likely to

affect the health of our patients. Thisinformation wil l assist in giving you the

best treatment and highest possiblestan-

dard ofcare. Therefore, we ask that you

complete this questionnaire that asks

about your use of alcoholic beverages

during the past year.Please answer as

accurately and honestly as possible. Your

health worker wil l discuss this issue with

you. A ll information wil l be treated in

strictconfidence.

Th isstatement should be followed by a

description of the types of alcoholic bev-

erages typically consumed in the country

or reg ion where the pat ient lives(e.g ., By

alcoholic beverages we mean your use of

wine, beer, vodka,sherry, etc.)If neces-

sary, include a descript ion of beverages

that may not be considered alcoho lic,

(e.g.cider, low alcohol beer, etc.). W ith

pa tients whose alcoho lconsumption is

prohibited by law,culture, or religion

(e.g., youths, observant Muslims), acknow l-

edgment of such prohibition and encour-

agement of candor may be needed .For

example,I understand others may think

youshould not drink alcohol at all, but it

is important in assessing your health to

know what you actually do.

Patient instructionsshould also clarify the

meaning of a standard drink . Questions

2 and 3 of AUDIT ask about drinkscon-

sumed . The meaning of this word d iffers

from one nation and culture to another.

It is important therefore to mention the

most common alcoho lic beverages likely

to be consumed and how much of each

constitutes a drink (approximately 10 grams

of pure ethanol).For example, one bottleof beer (330 ml at 5% ethanol), a glass

of w ine (140 ml at 12% ethano l), and a

shot of spirits(40 ml at 40% ethanol)

represent a standard drink of about 13 g

of ethanol.Since the types and amounts

of alcoholic drinks w il l vary accord ing to

culture and custom, the alcoholcontent

of typ icalserv ings of beer, w ine and sp irits

mus

t be determined to adapt the AUD

I

Tto particular set tings. See Appendix C .


17/41

OralAdministrat ion vs.Self-reportQuest ionnaire

The AUDIT may be administered either as

an oralinterview or as a self-report ques-

tionnaire. Each method carries its own

advantages and disadvantages that must

be weighed in light of time and cost con-

stra ints. The relat ive merits of using the

AUDI

T as

aninterv

iew v

s.

thes

elf-reportquestionnaire are summarized in Box 3.

Th e cogn itive capacities(literacy, forgetfu l-ness) and level of cooperation (defensive-ness) of the pat ient shou ld be considered .If the expectat ion is that primary careproviders w ill manage a ll the care thatpatients w ill receive for the ir a lcoho l prob-lems, an interview may have advantages.However, if the provider s responsib ili tyw ill be lim ited to offering brief advice topatients who screen positive and referringmore severe cases to other services, thequestionnaire method may be preferab le.

Whatever decision is made ,it must be con-sistent w ith imp lementation plans to estab-lish a comprehensive screening programme.

The AUDIT questions and responses are

presented in Box 4 in a format suggested

for an oral interview. Appendix B gives an

example of the self-report questionnaire.

Adaptation should be made to needs of

the particu lar s

creen ing programme as wellas the alcoho lic beverages most common ly

consumed in that society. Append ix C pro-vides gu idelines for translat ion and adapta-tion to national and localcon d itions.

If the AUDIT is administered as an interview,

it is important to read the questions as

wr itten and in the order ind icated. By fol-

low ing the exact wording, better compa-

rabil i

ty wil l

be obtained betw een yourresults and those obtained by other inter-

viewers. Most of the quest ions in theAUDIT are phrased in terms of how


Box 3

Advan tagesofDifferen tApproachestoAUDITAdministration

Quest ionnaire Interv iew

Takes less time A llowsclarification of ambiguous answers

Easy to adm inister Can be administered to patients w ith poor

reading skil ls

Suitab le for computer administration

and scoring

May produce more accurate answers A llowsseam less feedback to patient

and initiat ion of brief advice


18/41

ADMINISTRATIONGUIDELINESI 17

Box 4

TheAlcoholUseDisorders IdentificationTest: InterviewVersion

Read questions as wr itten.Record answers

carefully. Begin the AUD

IT by saying Now

Iam going to askyou some questions about your use of alcoholic beverages dur ing this past year. Exp lain what is meant

by alcoholic beverages by using local examples of beer, w ine , vodka, etc. Code answersin terms of

standard drinks .Place the correct answer number in the box at the r ight.

6. How often during the last year have you neededa first drink in the morning to get yourself go ingafter a h eavy drink ing session?

(0) Never(1) Less than monthly(2) Monthly(3) Weekly

(4) Da ily or almost da ily

1. How often do you have a drink containing alco-ho l?

(0) Never [Skip to Qs 9-10](1) Monthly or less(2) 2 to 4 times a month(3) 2 to 3 times a week(4) 4 or more times a week

7. How often during the last year have you had afeeling of guilt or remorse after drink ing?

(0) Never(1) Less than monthly(2) Monthly(3) Weekly(4) Da ily or almost da ily

4. How often during the last year have you foundthat you were not able to stop drink ing once youhad started?

(0) Never(1) Less than monthly

(2) Monthly(3) Weekly(4) Da ily or almost da ily

9. Have you or someone else been injured as aresult of your drink ing?

(0) No(2) Yes, but not in the last year(4) Yes, dur ing the last year

5. How often during the last year have you failed todo what was normally expected from youbecause of drink ing?


10 . Has a relat ive or friend or a doctor or anotherhealth worker been concerned about your drink-ing or suggested you cut down?

(0) No(2) Yes, but not in the last year(4) Yes, dur ing the last year

2. How many drinksconta ining alcohol do you haveon a typical day when you are drink ing?

(0) 1 or 2(1) 3 or 4(2) 5 or 6(3) 7, 8, or 9(4) 10 or more

8. How often during the last year have you beenunable to remember what happened the n ightbefore because you had been drink ing?


3. How often do you have six or more drinks on oneoccasion?


Skip to Questions 9 and 10if TotalScorefor Questions 2 and 3 = 0

Record total of specific items here

If totalis greater than recommendedcut-off,consult Users Manual.


19/41

often symptoms occur.Prov ide the

pa tient w ith the response categories given

for each question (for example,Never,

Several times a month,Daily). When a

response opt ion has been chosen , it is

useful to probe during the initial ques-

tions to be sure that the pat ient has

selected the most accurate response (for

example,Yousay you drink several times

a week.Is thisjust on weekends or doyou drink more orless every day?).

If responses are ambiguous or evasive ,

cont inue asking for clar ification by repeat-

ing the question and the response options,asking the patient to choose the best

one. At times answers are diff icult to

record because the patient may not drink

on a regular basis. For example, if the

patient was drink ing excessive ly duringthe month before an acc ident, but not

prior to that time , then it w il l be diff icult

to characterize the typ ical drink ing

sought by the question .In these casesit

is best to record the amount of drink ing

and related symptoms for the heaviest

drinking period in the past year, making

note of the fact that this may be atypical

or transitory for that ind ividual.

Record answerscarefully, making note of

any specialcircumstances, add itional infor-

mat ion , and clin ical observations. Often

pat ients w ill provide the interviewer w ith

usefu lcomments about the ir dr inking that

can be valuab le in the interpretation of the

AUDIT totalscore .

Adm inistering the AUDIT as a written ques-

tionnaire or by computer elim inates manyof the uncertaint ies of patient respo nses by

allow ing only specificcho ices.

However,it eliminates the informat ion

obtained from the interview format.

Moreover, it presumes literacy and ab il ity

of the patient to perform the required

actions.It may also require less time on

the part of hea lth workers, if patientscan

complete the process alone . W ith time at

a premium for both health workers and

patients, ways of shortening the screen ing

process mer it consideration .

ShorteningtheScreeningProcess

Adm in istered either ora lly or as a quest ion-

na ire,the AUDIT can usually be comp leted

in two to four minutes and scored in a

fe w seconds. However, for many patien ts

it is unnecessary to adm in ister the comp lete

AUDIT because they drink infrequently,

moderately, or absta in entire ly from a lco-

ho l. The interview version of the AUDIT

(Box 4) provides two opportun ities to skip

questions fo r such patients.If the pat ient

answers in response to Quest ion 1 that no

dr inking has occurred during the last year,

th e interviewer may skip to Questions 9-10 ,

responses to wh ich may ind icate past prob-

lems w ith alcohol.Pat ients who score points

on these questions may be considered at risk

if they beg in to drink again , and shou ld beadvised to avo id alcohol.It is recommended

that th isskip out instruction on ly be used

w ith the interview or computer-assisted

formats of the AUDIT.

A second opportunity to shorten AUDIT

screening occurs after Question 3 has

been answered.If the patient scored 0

on Questions 2 and 3, the interviewer

may skip to Questions 9-10 because the

patients drink ing has not exceeded the

low risk drinking limits.



20/41

The AUDIT is easy to score . Each of the

questions has a set of responses to

choose from, and each response has a

score rang ing from 0 to 4 .In the interview

format (Box 4) the interviewer enters the

score (the number w ith in parentheses)

correspond ing to the pat ients response

into the box beside each question .In

the self-report questionnaire format

(Appendix B), the number in the column

of each response checked by the patien t

should be entered by the scorer in the

extreme right-hand colum n. A ll the response

scoresshou ld then be ad ded and recorded

in the box labeled Total .

Totalscores of 8 or more are recom-

mended asind icators of hazardous and

harmful alcohol use, as well as possible

alcoho l dependence.(A cut-off score of

10 w il l provide greater specificity but at

the expense of sensitivity.)Since the

effects of alcohol vary w ith average body

weight and differencesin metabolism,

establishing the cut off point for all

women and men over age 65 one po int

lower at a score of 7 w il lincrease sensi-

tivity for these populat ion groups.

Selection of the cut-off point should beinf luenced by national and culturalstan-

dards and by clinician judgment , which

also determine recommended maximum

consumption allowances. Techn ically

speaking, higher scoressimp ly ind icate

greater like lihood of hazardous and

harmful drink ing. However,such scores

may also ref lect greater severity of a lcoho l

problem

s

and dependence,

as

well

as

agreater need for more intensive treatment.

More detailed interpretation of a patien ts

totalscore may be obtained by determin-

ing on wh ich questions po ints were

scored.In general, a score of 1 or more

on Question 2 or Question 3 indicates

consumption at a hazardousleve l.Points

scored above 0 on questions 4-6 (espe-

cially weekly or da ily symptoms) imp ly the

presence or incipience of a lcohol depen-

dence.Pointsscored on questions 7-10

ind icate that alcohol-re lated harm is

already being experienced . The total

score ,consumption level,signs of depen-

dence, and present harm allshould play

a ro le in determining how to manage a

pa tient. The final two questionsshould

also be reviewed to determine whether

pa tients give evidence of a past problem

(i.e., yes, but not in the past year).Even in the absence of current hazardous

drink ing, positive responses on these

itemsshould be used to discuss the need

for vigilance by the patient .

In most cases the total AUDIT score w il l

reflect the patientsleve l of risk related to

alcohol.In general health care sett ings

and in community surveys, most patien ts

w il lscore under the cut-offs and may beconsidered to have low risk of alcoho l-

related problems. A sma ller, but stil lsig-

nificant, portion of the popu lat ion is like-

ly to score above the cut-offs but record

most of their po ints on the first three

questions. A much sma ller proportion

can be expected to score very high , w ith

po ints recorded on the dependence-relat-

ed ques

tion

s

as

well

as

exhib

iting a

lco-ho l-re lated problems. As yet there has

been insufficient research to estab lish

SCORINGANDINTERPRETATION I 19

Scoringand Interpretation


21/41

precisely a cut-off point to distinguish

hazardous and harmful drinkers(who

wou ld benefit from a brief intervention)

from alcoho l dependent drinkers(who

should be referred for d iagnostic eva lua-

tion and more intensive treatment). Th is

is an important question because screen-

ing programmes designed to identify

cases of alcoho l dependence are like ly to

find a large number of hazardous and

harmful drinkersif the cut-off of 8 is

used . These patients need to be man-

aged w ith less intensive interventions.In

general, the higher the totalscore on the

AUD IT, the greater the sensitivity in find-

ing persons w ith alcohol dependence.

Based on experience gained in a study of

treatment matching w ith persons who

had a w ide range of a lcohol problem

severity, AUDIT scores were compared

w ith diagnostic data reflecting low, medi-

um and high degrees of alcoho l depen-

dence.It was found that AUDIT scores in

the range of 8-15 represented a medium

leve l of alcohol problems whereasscores

of 16 and above represented a high level

of alcoho l problems33 . On the basis of

experience ga ined from the use of theAUD IT in th is and other research,it is

suggested that the fo llow ing interpreta-

tion be given to AUDIT scores:

Scores between 8 and 15 are most

appropriate for simp le advice focused

on the reduction of hazardous drinking .

Scores between 16 and 19 suggest

brief counseling and cont inued moni-toring.

AUDIT scores of 20 or above clearly

warrant further diagnostic eva luation

for alcohol dependence.

In the absence of better research these

gu ide linesshou ld be considered tenta-

tive ,sub ject to clinical judgment that

takes into account the patient s medical

condition , family history of alcohol prob-

lems and perceived honesty in respond-

ing to the AUDIT questions.

While use of the 10-question AUDIT

questionna ire w il l be suff icient for the

vast ma jority of patien ts, specialcircum-

stances may require a clinicalscreening

procedure.For example, a patient may be

resistant, uncooperative , or unable to

respond to the AUDIT questions. If fur-

ther confirmation of possible dependenceis warranted , a physical exam ination pro-

cedure and laboratory tests may be used,

as described in Appendix D.



22/41

Using the AUDIT to screen patien tsis only

the first step in a process of helping

reduce alcohol-re lated problems and risks.

Health care workers must decide what

services they can provide to patien ts who

score positive . Once a positive case has

been ident ified , the next step is to provide

an appropriate intervention that meets th e

needs of each patient. Typ ically, alcohol

screening has been used primarily to find

cases of alcohol dependence, who are

then referred to specia lized treatmen t .In

recent years, however, advances in screen-

ing procedures have made it possible to

screen for risk factors,such as hazardous

drinking and harmful alcohol use. Using

the AUDIT TotalScore , there is a simp le way

to provide each patient w ith an appropri-

ate intervention , based on the level of risk .

W h ile th is d iscussion w ill fo cus on help ing

those patients who score positive on the

AUD IT,sound preventative practice also

calls for reporting screening results to

those who score negative . These patients

should be reminded about the benefits of

low risk drinking or abstinence and told

not to drink in certain circumstances,

such as those mentioned in Box 5.

Four leve ls of risk are shown in Box 6.

Zone I refers to low risk drinking or absti-

nence. The second level, Zone II,consists

of alcoho l use in excess of low-risk gu ide-

lines5, and is generally ind icated when the

AUDIT score is between 8 and 15 . A br ief

intervent

ion u

sing

simp

le adv

ice and pat

ien ted ucation materials is the most appropriate

course of action for these patients. Th e

th ird leve l, Zone III, issuggested by AUDITscoresin the range of 16 to 19 . Harmful

and hazardous drink ing can be managed

by a comb ination of simp le advice, brief

counseling and continued monitoring ,

w ith further diagnostic evalua tion ind icated

if the patient fails to respond or issuspected

of possible alcoho l dependence. The fourth

risk leve l issuggested by AUDIT scores in

excess of 20. These patientsshould be

referred to a specialist for d iagnostic evalu-at ion and possible treatment for alcoho l

dependence.If these serv ices are not avail-

ab le, these patientscan be managed in

primary care , especially when mutual he lp

organiza tions are able to provide commu-

nity-based support . Using a stepped-care

approach , patientscan be managed f irst at

the lowest leve l of intervent ion suggested

by their AUDI

Tsc

ore.

I

f they do not res

pondto the initialintervention , they should be

referred to the next leve l of care .

HOWTOHELPPATIENTSI 21

HowtoHelpPatients

Box 5

AdvisePatien tsnot toDrink

When operating a vehicle or

machinery

When pregnant or

consideringpregnancy

If a contraind icated medical

cond ition is present

After using certain medications,

such assedatives, analgesics,

and selected antihypertensives


23/41

Brief interventions for hazardous and

harmful drink ing constitute a variety of

activitiescharacterized by the ir low inten-

sity and short duration . They range from

5 minutes of simp le advice about how to

reduce hazardous drinking to severalses-

sions of brief counseling to address more

complicated cond itions36

.Intended toprovide early intervention, before or soon

after the onset of a lcoho l-re lated problems,

br ief interventionsconsist of feedback of

screen ing data designed to increase moti-

vation to change drink ing behaviour, as

well assimp le advice, health educat ion ,

skil l bu ilding, and practicalsuggestions.

Over the last 20 years procedures have

been developed that primary care practi-

tionerscan readily learn and practice toaddress hazardous and harmful drink ing .

These procedures are summarized in Box 7 .

A number of random ized controlled trials

have evaluated the efficacy of this approach,

show ing consistently positive benefits for


Box 7

ElementsofBriefInterven tions

Present screening results

Identify risks and discussconse-

quences

Provide medical advice

Solicit patient comm itment

Identify goalreduced drink ing or

abstinence G ive advice and encouragement

Box 6

RiskLevel Intervent ion AUDITscore*

Zone I A lcohol Educat ion 0-7

Zone II Simp le Advice 8-15

Zone III Simp le Advice plus Brief Counselingand Continued Monitoring 16-19

Zone IV Referral to Specialist for Diagnostic 20-40Eva lua tion and Treatment

*The AUDIT cut-off score may vary slightly depending on the countrys drink ing patterns, the alcoholcontent of

standard drinks, and the nature of the screening program. C linical judgment should be exercised in cases where

the patientsscore is not consistent w ith other evidence, or if the patient has a p rior history of a lcoh o l dependence.

It may a lso be instru ct ive to review the pat ien ts respo nses to ind ividua l qu est ions dea ling w ith dependence symp-to ms(Quest ions 4 , 5 and 6) and alcoh ol-re lated problems(Questions 9 and 10).Provide the next highest leve l of

intervent ion to patients who score 2 or more on Questions 4, 5 and 6, or 4 on Questions 9 or 10.


24/41

patientswho are not dependent on a lco-

ho l36 , 37 , 38 . A companion WHO manual,

Brief Intervention for Hazardous and

Harmful Drinking: A Manual for Use in

Primary Care, provides more informat ion

on this approach.

Referral to alcoho lspecialty care iscommon

among those primary care practitioners

who do no t have competency in treating

alcoho l use disorders and where specialty

care is ava ilab le. Consideration must be

given to the w illingness of patients to

accept referral and treatment. Many

patients underestimate the risks associat-

ed w ith drinking; others may not be pre-

pared to admit and address their depen-

dence. A brief intervention , adapted to

the purpose of initiat ing a referral usingdata from a clinical exam ination and

blood tests, may help to address pa tien t

resistance.Follow-up w ith the patien t

and the specialty provider may also

assure that the referral is accepted and

treatment is received.

Diagnosis is a necessary step follow ing

high positive scoring on the AUDIT,since

the instrument does not provide suffi-cient basis for establishing a manage-

ment or treatment plan. While persons

associated w ith the screening programme

should have a basic famil iarity w ith the

criteria for alcohol dependence, a quali-

fied professiona l who is tra ined in the

diagnosis of alcoho l use disorders4 shou ld

conduct th is assessment. The best

method of es

tablis

hing a d

iagno

sisis

through the use of a standardized ,struc-

tured, psychiatric interview,such as the

C IDI39 or the SC AN40 . The alcoho lsections

of these interviews require 5 to 10 m inutes

to comp lete.

The Tenth revision of the International

Classification of Diseases(ICD-10)4 pro-

vides detailed guide lines for the diagnosis

of acute a lcoho l intoxication , harmful use,

alcoho l dependence syndrome, w ithdrawal

state, and related medical and neuropsy-

chiatriccond itions. The ICD-10 criteria for

the alcohol dependence syndrome are

described in Box 8.

Detoxificat ion may be necessary for some

pa tients. Special attention should be paid

to patien ts whose AUDIT responses ind i-

cate daily consumption of large amounts

of alcohol and/or positive responses toquestions ind icat ive of possible depen-

dence (questions 4-6). Enquiry should be

made as to how long a patient has gone

since having an alcohol-free day and any

prior experience of w ithdrawalsymp-

toms. Th is information , a physical exam i-

na tion , and laboratory tests(see C linical

Screening Procedures, Appendix D) may

inform a judgment of whether to recom-

mend detoxificat ion. Detoxificat ionshou ld be provided for patien ts like ly to

experience moderate to severe w ithdraw-

al not only to m inimize symptoms, but

also to prevent or manage seizures or

de lirium , and to facil itate acceptance of

therapy to address dependence. While

inpatient detoxificat ion may be necessary

in a sma ll number of severe cases, ambu-

latory or home detoxificat ion

can be used

successfu lly w ith the majority of less

severe cases.

HOWTOHELPPATIENTSI 23


25/41

Med ical management or treatment of

alcoho l dependence has been described

in previous WHO publicat ions41 . A variety

of treatments for alcoho l dependence

have been developed and found

effective42 .Significant advances have

been made in pharmacotherapy, family

and socialsupport therapy, re lapse pre-vention , and behaviour-oriented skil ls

tra ining interventions.

Because the diagnosis and treatment of

alcohol dependence have developed as a

specialty w ith in the mainstream of med-

icalcare ,in most countries pr imary care

practitioners are not trained or experienced

in its diagnosis or treatment.In such cases

pr imary care screening programmes must

estab lish protoco ls for referring patientssuspe cted of being alcoho l dependent

who need further d iagnosis and treatment.


Box 8

ICD-10Criteriaforthe AlcoholDependenceSyndrome

Three or more of the fo llow ing manifesta tionsshou ld have occurred together for at

least 1 month or, if persisting for periods of less than 1 month ,shou ld have occurred

together repeatedly w ith in a 12-month period:

a strong desire or sense of compulsion to consume alcohol; impaired capacity to control drink ing in terms of its onset , terminat ion , or leve lsof

use, as ev idenced by: alcohol being often taken in larger amounts or over a longer

period than intended; or by a persistent desire to or unsuccessfu l efforts to reduce

or control alcohol use;

a physiolog ical w ithdrawalstate when alcoho l use is reduced or ceased , as evidenced

by the characteristic w ithdrawa lsyndrome for alcoh ol, or by use of the sam e (or close-

ly related)substance w ith the intent ion of relieving or avoid ing w ithdrawa lsymptoms;

ev idence of to lerance to the effects of a lcoho l,such that th ere is a need for sign ifi-

cantly increased amounts of a lcoho l to ach ieve intoxication or the desired effect , ora marked ly d im in ished effect w ith continued use of the same amount of a lcoho l;

preoccupation w ith alcoho l, as manifested by important alternative pleasures or

interests be ing given up or reduced because of drinking; or a great deal of time

be ing spent in activities necessary to obtain, take, or recover from the effects of

alcoho l;

persistent alcoho l use desp ite clear evidence of harmfu lconsequences, as ev idenced

by continued use when the individua l is actua lly aware, or may be expected to be

aware, of the nature and extent of harm .

(p.57 , WH O , 1993)


26/41

Alcoholscreening and appropriate

pat ien t care have been recogn ized

w idely as essential to good medical prac-

tice.Like many medical practices that

achieve such recognition, there is often a

fa ilure to imp lement effective technolo-

gies w ith in organized systems of health

care .Imp lementation requiresspecial

efforts to assure compliance of individual

practitioners, overcome obstacles, and

adapt procedures to specialcircum-

stances.Research into imp lementation

has begun to produce usefu l gu ide lines

for effective imp lementation43 , 44 .Four

ma jor e lementshave emerged ascritical

to success :

planning;

tra ining; monitoring; and

feedback.

Planning is necessary not only to design

the alcoholscreening programme but

also to engage participants in the own-

ership of the programme. Every primary

care practice is un ique. Each has estab-

lished special proceduressuited to itsphysicalsett ing ,social and cultura l envi-

ronment, pa tient populat ion, econom ics,

staffing structure, and even individua l

personalities. Thus, adapting AUDIT

screening to each practice situation must

invo lve fitt ing its essential elements into

th iscontext in a way that is most like ly to

achieve susta ined success. If screening for

other health conditions and risk factors is

already part of standard practice, those

procedures may provide a usefulstarting

Programme Implementation

place. However, both policy and proce-

dural decisions w il l be required.

It is generally he lpfu l to involve in plan-

ning the staff who w il l participate in or

be affected by the screening operation .

Participat ion of persons w ith diverse per-

spectives, experience, and responsibil ities

is most like ly to identify obstacles and

create ways to remove or surmount

them.In addition, the invo lvement of

staff in planning yields a sense of ow ner-

ship over the resulting imp lementation

plan. Th isislike ly to increase the commit-

ment of individua ls and the group to fo l-

low the plan and make improvements

along the way that w il l assure success.

A partial list of imp lementation issues on

which planning is he lpful are presented

in Box 9. An imp lementation plan should

receive formal approva l at whatever

level(s) required before training begins.

Training is essen tial to preparing a health

care organizat ion to imp lement its plan-

ning. However, tra ining w ithout a man-

agement decision to imp lement a screen-

ing programme is likely to be ineffective

and even counter-productive . A trainingpackage has been developed31 to sup-

port imp lementation of AUDIT screening

and brief intervention (See Appendix E).

Tra ining should address the critical issues

of why screening is important , what con-

ditionsshould be identified, how to use

the AUDIT, and optima l procedures to

assure success. Effective training should

invo

lve

s

taffin a deta

iled d

iscussi

on oftheir functions and responsibil ities w ith in

the new programme plan.It should also

PROGRAMMEIMPLEMENTATION I 25


27/41

provide supervised practice in administer-

ing the AUDIT instrument and any other

procedures planned (e.g., brief interven-

tions, referral, etc.).

In some countries many people, even

medicalstaff, are accustomed to think

on ly of alcohol dependence when other

issues related to alcohol are raised.It is

not uncommon for health workers to

be lieve that peop le w ith alcohol prob-lemscannot be he lped un less they h it

bottom and seek treatment , and that

the only recourse is total abstinence.

Some people who ho ld these be liefs may

find a programme of screening and brief

intervention to be fruitless or threaten-

ing .It iscritical that specialcare is taken

to allow such issues to be addressed

openly, frankly, and w ith attention to the

best scien tific evidence. W ith sound

exp lanation and patience, most medical

staff w il l either understand the value of

screening or suspend judgment untilexperience allows a determination of its

va lue .


Box 9

Implemen tationQuestions

Which patients w il l be screened?

How often w il l patients be screened?

How w il lscreening be coordinated w ith other activities?

Who w il l administer the screen?

What provider and patient materials w il l be used?

Who w il l interpret results and help the patient?

How w il l medical records be maintained?

What follow-up actions w il l be taken?

How w il l pa tients need ing screening be identified?

When during the patient s visit w il lscreening be done?

What w il l be the sequence of actions?

How w il l instruments and materials be obtained,stored, and managed?

How w il l fo llow-up be scheduled?


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Monitoring is an effective way to improve

the quality of screening programme

imp lementation . There are various ways

of measuring the success of an alcohol

screening programme. The number of

screenings performed may be compared

to the number of people presenting who

should have been screened under the

established policy, producing a percent-

age of screening success. Record ing and

totaling the percentage of patients who

screen positive is also a useful measure

that encouragesstaff by estab lishing the

need for the service. Determining the

percentage of patients who received the

appropriate intervention (brief interven-

tion , referral, diagnosis, etc.) for their

AUD IT score is a further measure of pro-

gramme performance.

Finally, a sma ll

sample of patien ts who had screened

positive six to twelve months before

might be surveyed to provide at least

anecdotal evidence of outcome success.

Re-administration of the AUDIT can serve

as the basis for measuring quantita tive

outcomes.

Whatever criteria of success are

employed, frequent feedback to all par-ticipat ing staff is essen tial for results to

contribute to enhanced programme per-

formance in the early periods of imp le-

mentation. Written reports and discus-

sion at regular staff meetings w il l also

provide occasions at which staff can

address any problems that may be inter-

fering w ith success.

PROGRAMMEIMPLEMENTATION I 27


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The AUDIT was developed on the basis

of an extensive six-nation validation

trial1, 2. Add itional research has been

conducted to eva luate its accuracy and

ut il ity in different set tings, populat ions,

and cultural groups10 . To provide further

gu idance to this process, it is recom-

mended that health researchers use the

AUD IT to answer some of the follow ing

questions:

Does AUD IT predict future alcoho l

problems as well as the patien ts

response to brief intervention and more

intensive treatment? Thiscan be evalu-

ated by conducting repeated A UDIT

screening on the same ind ividual. Total

scorescan be correlated w ith various

ind icators of future symptomatology.It

wou ld be desirable to know, for exam-

ple, whether AUDIT assesses alcoho l-

related problems along a continuum of

severity, whether severity scores increase

progressive ly among ind ividuals who

continue to drink heavily, and whether

scores diminish sign ificant ly fo llow ing

advice,counseling , and other types of

intervention . A screening test shou ld

not be conceived in isolation fromintervention and treatment.It must be

eva luated in terms of its impact on the

morbidity and mortality of the popula-

tion at risk.Itscontribution to secondary

and primary prevention is therefore

dependent on the availab il ity of effec-

tive intervention strategies.

What is the sensitivity,specificity and

pred ictive power of the AUD IT in d iffer-ent risk groups using d ifferent va lidat ion

criteria? In future evaluations of the AUDIT

screening procedures, careful attention

shou ld be given to the alcohol-re lated

phenomena to be detected or pred icted .

Emphasisshou ld be g iven to the assess-

ment of initial risk leve ls, harmful use,

and alcoho l dependence. The demands

of methodo log ica lly sound validat ion

requ ire the use of independent d iagnos-

ticcrite ria , wh ich themselves have been

va lidated . Two instruments that may beusefu l for th is purpose are the

Composite International D iagnostic

Interview (C IDI) and the Schedu les fo r

C lin ical Assessment in Neuropsych iatry

(SC AN)39 , 40 . Both of these interviews

provide independent verification of a

variety of alcoho l use d isorders accord-

ing to ICD-10 and other d iagnost icsys-

te ms. The testcou ld be improved byfo cusing on more carefully defined risk

groups and more specif ic a lcoho l-re lated

prob lems.Specificat ion of cut-off po ints

is needed for target popu lat ions whose

prob lems are to be the focus of screen-

ing w ith AUDIT, especially persons w ith

harmfu l use and a lcoho l dependence .

What are the pract ica l barriers to

screen ing w ith the AUD

I

T?I

mportantconstra ints on screen ing tests are

imposed by cost considerations and by

the acceptabil ity of screening to both

hea lth professiona ls and the intended

target popu lat ions. When a screen ing

test is expensive , the resu lts of a screen-

ing programme may not justify itscost .

Th is is a lso true whe n the procedure is

t ime consum ing , overly invasive , or oth-

erw ise offensive to the target group .Th is type of process eva luat ion shou ld

be conducted w ith AUDIT.


AppendixAResearchGuidelinesfortheAUDIT


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Can the AUDIT be scored to produce

separate assessments of hazardous use,

harmful use, and alcohol dependence?

If screening can be differentiated into

these separate domains, it may prove

usefu l for the purpose of evaluat ing

different educat ional and treatment

approaches to secondary prevention .

A lternative ly, the AUDIT TotalScore

provides a general measure of severity

that may be useful for treatment

matching and stepped-care approaches

to clinical management (i.e., providing

the lowest level of intervention that

addresses the patient s immediate

needs).If the patient does not respond ,

the next higher step is provided.

A lthough AUDIT scoresin the range of

8 to 19 seem appropriate to brief inter-vent ions, further research is needed to

find the optima lcut-off points that are

most appropriate for simp le advice,

brief counseling, and more intensive

treatment .

How can the AUDIT be used in ep idem i-

olog ical research? The AUDIT may have

applicat ions as an epidem iolog ical tool

ins

urveys

of healthc

linics,

healths

er-vice systems, and general population

samples. The AUDIT was developed as

an international instrument but it cou ld

also be used to compare samp les drawn

from different national and cultural

groups, w ith respect to the nature and

prevalence of hazardous drink ing,

harmful drink ing, and alcoho l depen-

dence. Before this is done it would be

usefu l to develop norms for various risklevelsso that ind ividual and group scores

can be compared to the distribution of

scores w ith in the general populat ion .

What is the concurrent validity of the

AUDIT items and totalscores when

compared w ith different ob jective

ind icators of alcohol-re lated problems,

such as blood alcoholleve l, biochem ical

markers of heavy drinking , pub lic

records of alcohol-related problems,and observational data obtained from

persons know ledgeab le about the

pa tient's drinking behaviour. To the

extent that verbal report procedures

may have intrinsic limitat ions, it would

be useful to evaluate under what cir-

cumstances AUD IT results are biased or

otherw ise invalid .Procedures to increase

the accuracy of AUDIT should also be

investigated .

How acceptable is the AUDIT to prima-

ry care workers? How can screening

procedures best be taught in the con-

text of educat ing health professionals?

How extensive ly are screening proce-

dures using AUDIT applied once stu-

dents or health workers are trained?

APPENDIXAI 29


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In some set tings there may be advan-

tages to administering the AUDIT as a

questionnaire completed by the pat ient

rather than as an oralinterview.Such an

approach often saves time ,costs less,

and may produce more accurate answers

by the patien t. These advantages may

also result from administration via com-

puter. The AUDIT questionnaire format

presented in Box 10 may be useful for

such purposes.

Use of the skip outs provided in the oral

interview (Box 4 on page 17) is like ly to

be too diff icult for patients to follow in

a paper administration. However, they

are easily achieved automatically in com-

puterized applicat ions.

Adm inistrators are encouraged to add

il lustrations of local,commonly availab le

beverages in standard drink amounts.

Question 3 may requ ire modificat ion (to

4 or 5 drinks), depend ing on the number

of standard drinks required to total 60

grams of pure ethanol(See Appendix C).

Scoring instructions: Each response is

scored using the numbers at the top ofeach response column . Write the appro-

priate number associated w ith each answer

in the column at the right . Then add all

numbers in that column to obtain the

TotalScore .

Space at the bottom of the form may be

designated For Office Use Only to con-

tain

ins

truction

s

or places

to documentactions taken by health workers who

administer the AUDIT or provide brief

interventions. Such material, however,

shou ld be sufficient ly coded so as not to

compromise patients' honesty in answer-

ing AUDIT questions.


AppendixBSuggestedFormatforAUDITSelf-ReportQuestionnaire


32/41

APPENDIXBI 31

Questions 0 1 2 3 4

1. How often do you have Never Monthly 2-4 times 2-3 times 4 or more

a drink containing alcohol? or less a month a week times a week

2. How ma ny drinkscontaining 1 or 2 3 or 4 5 or 6 7 to 9 10 or more

alcohol do you have on a typical

day when you are drink ing ?

3. How oft en do you have six or Never Less than Monthly Weekly Da ily or

more drinks on one monthly almost

occasion? daily

4. How often during the last Never Less than Monthly Weekly Da ily or

year have you found that you month ly almost

were not able to stop drink ing daily

once you had started?

5. How often during the last Never Less than Monthly Weekly Da ily or

year have you fa iled to do monthly almost

what was normally expected of daily

you because of drink ing ?

6. How often during the last year Never Less than Monthly Weekly Da ily or

have you needed a f irst drink monthly almost

in the morning to get yourself da ily

go ing after a heavy drink ing

session ?

7. How often during the last year Never Less than Monthly Weekly Da ily orhave you had a fee ling of gu ilt monthly almostor remorse after drink ing? daily

8. How often during the last year Never Less than Monthly Weekly Da ily or

have you been unab le to remem- monthly almostber what happened the night dailybefore because of your drink ing ?

9. Have you or someone else No Yes, but Yes,

been injured because of not in the during the

your drink in g? last year last year

10 . Has a re lat ive , fr ien d , do ctor,or No Yes, but Yes, other health care worker been not in the during the

concerned about your drink ing last year last year

or suggested you cut down?

Total

Box 10

The AlcoholUseDisorders IdentificationTest: Self-ReportVersion

PATIENT: Because alcoh o l use can affect your hea lth and can interfere w ith certain med icat ions an dtreatments, it is important that we ask some questions about your use of alcohol. Your answers

w ill remain confidentialso please be honest.

Place an X in one box that best describes your answer to each question .


33/41

In some cultura lset tings and linguisticgroups, the AUDIT questionscannot be

translated literally. There are a number of

sociocultural factors that need to be

taken into account in addition to seman-tic meaning.For example, the drink ing

customs and beverage preferences of cer-

ta in countries may require adaptation ofquestions to conform to localconditions.

W ith regard to translat ion into other lan-

guages, it shou ld be noted that the AUD ITqu estions have been translated into Spanish,Slavic, Norweg ian ,French, German,Russian ,Japanese,Swah ili , and several other lan-guages. Th ese translations are availab le bywriting to the Department of Menta lHealth and Substance Dependence,WorldHealth Organizat ion , 1211 Geneva 27,Sw itzerland . Before attempting to trans-

late AUDIT into other languages, interest-ed ind ividualsshou ld consult w ith WHO

Headquarters about the procedures to be

fo llowed and the availabil ity of othertranslat ions.

WhatisaStandardDrink?In different countries, health educatorsand researchers employ different defini-

tions of a standard unit or drink because

of differences in the typicalserving sizesin that country.For example,

1 standard drink in Canada: 13.6 g of

pure alcoho l1 s drink in the UK: 8 g

1 s drink in the USA: 14 g1 s dr ink in Australia or New Zea land: 10 g1 s dr ink in Japan: 19 .75 g

In the AUDIT, Questions 2 and 3 assume

that a standard drink equiva len t is 10 gramsof alcoho l. You may need to ad just the

number of drinksin the response categories

for these questions in order to fit the

most common drink sizes and alcoho l

strength in your country.

The recommended low-risk drink ing levelset in the brief intervention manualandused in the WHO study on brief inter-ventionsis no more than 20 grams ofalcohol per day, 5 days a week (recom-mending 2 non-drink ing days).

HowtoCalculatetheContentofAlcoholin aDrinkThe alcoho lcontent of a drink depends onthe strength of the beverage and the vo l-

ume of the conta iner. There are w ide varia-tions in the strengths of alcoho lic bever-

agesand the drink sizescommonly used indifferent countries. A WHO survey45 ind i-

cated that beer contained between 2%

and 5% volume by volume of pure a lcoho l,w inescontained 10 .5% to 18.9 % ,sp iritsvaried from 24 .3% to 90% , and cider from1 .1% to 17% . Therefore , it is essential toadapt drink ing sizes to what is most com-mon at the locallevel and to know roughlyhow much pure alcohol the person con-

sumes per occasion and on average.

Another consideration in measuring the

amount of alcoho lcontained in a stan-dard drink is the conversion factor of

ethano l. That allows you to convert any

vo lume of a lcoho l into grammes.For eachmilliliter of ethano l, there are 0 .79 grammesof pure ethanol.For example,

1 can beer (330 m l) at 5% x (strength)0.79 (conversion factor) = 13 grammesof ethanol

1 glass w ine (140 ml) at 12% x

0.79 = 13 .3 grammes of ethanol1 shot spirits(40 ml) at 40% x

0.79 = 12 .6 grammes of ethanol.


AppendixCTranslationandAdaptationtoSpecificLanguages,

CulturesandStandards


34/41

Aclinical examination and laboratory

testscan sometimes be helpful in the

detection of chronic harmful alcohol use.

C linicalscreening procedures have been

developed for this purpose34 . These

include tremor of the hands, the appear-

ance of blood vessels in the face, and

changes observed in the mucous mem-

branes(e.g., con junctivitis) and oralcavity

(e.g ., g lossitis), and elevated liver enzymes.

Only qualified health workersshould

conduct the exam ina tion .Several of

the items require explanation in order

to make a reliab le diagnosis.

Con junctiva l injection . The condition of

the conjunctiva l tissue is eva luated on

the basis of the extent of cap il laryengorgement and sclera l jaund ice.

Examina tion is best conducted in clear

daylight by asking the patient to direct

his gaze upward and then downward

while pu ll ing back the upper and lower

eye-lids. Under normalconditions, the

normal pearly whiteness is w ide ly dis-

tributed .In contrast,capil lary engorge-

ment is reflected in the appearance of

burgundy-coloured vascular elements

and the appearance of a greenish-yel-

low tinge to the sclera.

Abnormalskin vasculariza tion . Th is is

best evaluated by examination of the

face and neck. These areas often give

evidence of fine w iry arterioles that

appear as a reddish blush. Other signs

of chronic alcoho l ingestion include theappearance of 'goose-flesh " on the

neck and ye llow ish b lotches on the skin .

Hand tremor. Th isshou ld be estimated

w ith the arms extended anteriorly, half

bent at the e lbo ws, w ith the hands

rotated toward the m idline .

Tongue tremor. Th isshould be evaluat-

ed w ith the tongue protruding a short

distance beyond the lips, but not too

excessive ly.

Hepatomega ly. Hepaticchangesshou ld

be evaluated both in terms of volume

and consistency.Increased volume can

be gaged in terms of finger breadths

be low the costal margin. Consistency

can be rated as normal, firm , hard, or

very hard.

Several laboratory tests are useful in thedetection of alcohol misuse.Serum

gamma-glutamyl transferase (GGT),car-

bohydrate deficient transferrin (CDT),

mean corpuscular volume (MCV) of red

blood cells and serum aspartate amino

transferase (AST) are like ly to provide, at

re lat ive ly low cost, a possible ind icat ion

of recent excessive alcoholconsumption .

It shou ld be noted that fa lse positivescan

occur when the ind ividual uses drugs

(such as barbiturates) that induce GGT, or

has hand tremor because of nervousness,

neurolog ical disorder, or nicot ine depen-

dence.

APPENDIXDI 33

AppendixDClinicalScreeningProcedures


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Tra ining materials and other resources

have been deve loped to teach AUDIT

screen ing and brief intervention tech-

niques. These include videos, instructor's

manuals, and leaflets.

Resources that can be used to obtain

tra ining to use the AUDIT to screen for

alcoho l problems are listed below:

Anderson,P. A lcohol and primary health

care. Wor ld Hea lth Organ ization ,Reg iona l

Publications, European Ser ies no . 64, 1996.

Pro ject NEADA (Nursing Educat ion in

A lcoho l and Drug Abuse),consists of

a 30 minute video entitled A lcoho l

Screening and Brief Intervention and an

Instructor's Manual31 w ith lecture mate-

rial, role playing exercises, gu idelines forgroup discussions, and learner activity

assignments. Availab le through the U.S.

National C learinghouse on A lcoho l and

Drug Information: www.health .org or

call 1-800-729-6686 .

A lcoho l risk assessment and intervention

(ARA I) package . Ontario , Co llege of Fam ily

Physi

cians of Canada, 1994.

Sull ivan, E., and Fleming, M . A Guide

to Substance Abuse Services for Primary

Care C linicians, Treatment Improvement

ProtocolSeries, 24,U.S. Department of

Health and Human Services, Rockvil le,

MD 20857, 1997.


AppendixETrainingMaterialsforAUDIT


36/41

1. Saunders, J.B., Aasland , O .G ., Babor,

T.F., de la Fuente ,J.R. and Grant,

M . Development of the A lcoho l Use

DisordersIdentificat ion Test (AUD IT):

WHO collaborat ive project on early

detection of persons w ith harmful

alcoho lconsumption .II.Addiction, 88 ,

791-804, 1993.

2. Saunders, J.B., Aasland , O .G .,

Amundsen , A . and Grant, M . A lcoho l

consumption and related probl

Audit Romania Alcool

Documents

Transcript of Audit Romania Alcool