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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.
4 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATIONTEST
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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.
6 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATIONTEST
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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
8 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATIONTEST
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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14 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATION TEST
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
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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 .
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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
16 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATION TEST
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
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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?
(0) Never(1) Less than monthly(2) Monthly(3) Weekly(4) Da ily or almost da ily
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?
(0) Never(1) Less than monthly(2) Monthly(3) Weekly(4) Da ily or almost da ily
3. How often do you have six or more drinks on oneoccasion?
(0) Never(1) Less than monthly(2) Monthly(3) Weekly(4) Da ily or almost da ily
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.
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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.
18 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATION TEST
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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
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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.
20 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATION TEST
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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
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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
22 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATION TEST
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.
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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
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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.
24 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATION TEST
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)
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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
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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 .
26 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATION TEST
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.
28 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATION TEST
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.
30 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATION TEST
AppendixBSuggestedFormatforAUDITSelf-ReportQuestionnaire
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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 .
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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.
32 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATION TEST
AppendixCTranslationandAdaptationtoSpecificLanguages,
CulturesandStandards
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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.
34 I AUDIT I THEALCOHOLUSEDISORDERSIDENTIFICATION TEST
AppendixETrainingMaterialsforAUDIT
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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
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