THE PHYSICIANS' GUIDE TO HELPING PATIENTS WITH ALCOHOL
U.S. Department of Health and Human Services, Public Health Service,
National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism
NIH Publication No. 95-3769, Printed l995
Flowchart for Alcohol Screening
and Brief Intervention
This Guide was developed by the National Institute on Alcohol
Abuse and Alcoholism (NIAAA) in conjunction with an interdisciplinary working
group of alcohol researchers and health professionals. The clinical recommendations
in this Guide are based on the findings of more than a decade of
research on the health risks associated with alcohol use and on the effectiveness
of alcohol screening and intervention methods. NIAAA plans to update this
Guide periodically to reflect continuing advances in research.
NIAAA would like to acknowledge the contributions of members of the Working
Group on Screening and Brief Intervention, including the following: John
Allen, Ph.D.; Peter Anderson, M.D.; Thomas Babor, Ph.D.; Kendall Bryant,
Ph.D.; David Buchsbaum, M.D.; Jonathan Chick, M.D.; Frances Cotter, M.A.,
M.P.H.; Michael Fleming, M.D., M.P.H.; Richard K. Fuller, M.D.; Nick Heather,
Ph.D.; Yedy Israel, Ph.D.; Cherry Lowman, Ph.D.; William R. Miller, Ph.D.;
Judith Ockene, Ph.D.; and Allen Zweben, D.S.W.
NIAAA also would like to thank other collaborators, including the following:
Michael Fleming, M.D., M.P.H., and Frances Cotter, M.A., M.P.H., for their
leadership in writing this Guide; the College of Family Physicians
of Canada Alcohol Risk Assessment and Intervention (ARAI) Project Steering
Committee for sharing their expertise and early drafts of brief intervention
materials; and Eve Shapiro and colleagues at CSR, Incorporated, for their
expertise in editing and designing this Guide.
As a primary care physician, you are in an excellent position to identify
and manage patients at risk for alcohol-related problems. Alcohol-related
problems are common in primary care practice: An estimated 25 percent of
adults in the United States either report drinking patterns that put them
at risk for developing problems or currently have alcohol-related problems,
including alcohol abuse or dependence.* Primary care physicians are the
entry point into the health-care system for many individuals. Furthermore,
because you are concerned with the overall health of an individual, you
generally see patients more frequently than do other health-care professionals.
Primary care physicians are busy. Yet you want to practice good medicine
and are willing to take time to address your patients' alcohol problems.
This Guide, prepared by the National Institute on Alcohol Abuse and
Alcoholism, provides you with a step-by-step approach to identifying and
managing these problems and offers practical advise on making alcohol screening,
assessment, and brief intervention procedures a routine part of your clinical
practice. There are important reasons for doing so. Untreated alcoholism
results in a variety of social, economic, and medical consequences. Alcohol
use can complicate treatment for medical problems, interfere with prescribed
medications, or lead to adverse side effects. Most importantly, left untreated,
alcohol abuse and alcoholism often result in severe or fatal outcomes.
Your patients look to you for advice about the risks and benefits associated
with drinking. Research, in fact, demonstrates that simply discussing your
concerns about alcohol use can be effective in changing many patients' drinking
behavior before problems become chronic.
We commend this Guide to your attention and hope that you will make
it an integral part of your practice.
Enoch Gordis, M.D.
National Institute on Alcohol Abuse and Alcoholism
*Seven percent of the U.S. population -- approximately l4 million adults
-- meet the diagnostic criteria for alcohol abuse or dependence
WHAT YOUR PATIENTS SHOULD KNOW ABOUT ALCOHOL USE
Most adults who drink alcohol drink in moderation and are at low risk
for developing problems related to their drinking. However, all drinkers,
including low-risk drinkers, should be aware of the health risks associated
with alcohol consumption. Provide your patients with information and advice
about the risks of drinking.
RECOMMENDATIONS TO PATIENTS FOR LOW-RISK DRINKING
Advise those patients who currently drink to drink in moderation.
Moderate drinking is defined as follows:
- Men -- no more than two drinks per day
- Women -- no more than one drink per day
- Over 65 -- no more than one drink per day
Note: A standard drink is l2 grams of pure alcohol, which is equal to
one l2-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or
l.5 ounces of distilled spirits.
Advise patients to abstain from alcohol under certain conditions:
- when pregnant or considering pregnancy
- when taking a medication that interacts with alcohol
- if alcohol dependent
- if a contraindicated medical condition is present (e.g., ulcer, liver
If a patient is at risk for coronary heart disease, discuss the potential
benefits and risks of alcohol use:
Light to moderate drinking is associated with lower rates of coronary heart
disease in certain populations (e.g., men over 45, postmenopausal women).
Infrequent or nondrinkers are not advised to begin a regimen of light to
moderate drinking to reduce the risk of coronary heart disease because vulnerability
to alcohol-related problems cannot always be predicted. Similar protective
effects can likely be achieved through proper diet and exercise.
Women and the elderly have smaller amounts of body water than men; therefore,
they achieve a higher blood alcohol concentration than men after drinking
the same amount of alcohol
Exposing a fetus to alcohol can cause a broad range of birth defects referred
to as fetal alcohol syndrome (FAS) or alcohol-related birth defects (ARBD).
Although FAS/ARBD is associated with excessive alcohol consumption during
pregnancy, studies also have reported neurobehavioral deficits in infants
born to mothers reporting drinking an average of one drink per day during
Studies indicate that heavier episodic drinking (i.e., the consumption of
more than four drinks per occasion by men and more than three drinks per
occasion by women) impairs cognitive and psychomotor functions and increases
the risk of alcohol-related problems, including accidents and injuries.
SCREENING AND BRIEF INTERVENTION PROCEDURES
Recommended screening and brief intervention procedures include four
I...Ask about alcohol use.
II..Assess for alcohol-related problems.
III.Advise appropriate action (i.e., set a drinking goal, abstain,
or obtain alcohol treatment).
IV.Monitor patient progress.
STEP I. -- ASK ABOUT ALCOHOL USE
Ask all patients:
- Do you drink alcohol, including beer, wine, or distilled spirits?
Ask current drinkers about alcohol consumption:
- On average, how many days per week do you drink alcohol?
- On a typical day when you drink, how many drinks do you have?
- What is the maximum number of drinks you had on any given occasion
during the last month?
Ask current drinkers the CAGE questions:
- Have you ever felt that you should Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt bad or Guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your
nerves or get rid of a hangover (Eye opener)?
If there is a positive response to any of these questions:
- ASK: Has this occurred during the past year?
A patient may be at risk of alcohol-related problems
> l4 drinks per week or
- > 4 drinks per occasion
> 7 drinks per week or
- > 3 drinks per occasion
- one or more positive responses to the CAGE that have occurred in the
When is screening for alcohol problems appropriate?
- as part of a routine health examination
- before prescribing a medication that interacts with alcohol
- in response to presenting problems that may be alcohol-related
STEP II. -- ASSESS FOR ALCOHOL-RELATED PROBLEMS
Patients who screen positive should be assessed to determine the nature
and extent of their alcohol-related problems. Use the assessment procedures
described below to determine problem severity, as follows: l) at increased
risk for developing alcohol-related problems, 2) currently experiencing
alcohol-related problems, or 3) may be alcohol dependent.
1. At Increased Risk for Developing Alcohol-Related Problems
- drinking above recommended low-risk consumption levels or in high-risk
- personal or family history of alcohol-related problems
- Ask about typical drinking patterns: How long have you been drinking
this amount? How many times in a week (or month) do you have four or more
drinks on one occasion? What is the most you have consumed on one occasion
during the past year?
- Ask about personal and family history: Have you or anyone in your immediate
family ever had a drinking problem?
Note: For many conditions, there is a dose-response relationship
between alcohol consumption and risk. This applies to cirrhosis of the liver;
cancers of the oropharynx, larynx, liver, and breast; hypertension; and
2. Currently Experiencing Alcohol-Related Problems
- one or two positive responses to the CAGE that have occurred in the
- evidence of alcohol-related medical or behavioral problems
Review your patient's medical history for evidence of alcohol-related
medical problems, such as:
- chronic abdominal pain
- liver dysfunction
- sexual dysfunction
- sleep disorders
Note: Chronic heavy use of alcohol (i.e., three or more drinks
per day) may be associated with elevations in serum gammaglutamyltransferase
(GGT). This can be an indicator of excessive drinking.
- Ask about interpersonal or work-related problems: Has your drinking
ever caused you problems, such as problems with your family, problems with
your work (or school) performance, or accidents/injuries?
3. May Be Alcohol Dependent
- three or four positive responses to the CAGE that have occurred in
the past year
- evidence of one or more of the following symptoms:(l)
- Compulsion to drink -- preoccupation with drinking
- Impaired control -- unable to stop drinking once started
- Relief drinking -- drinking to avoid withdrawal symptoms
- Withdrawal -- evidence of tremor, nausea, sweats, or mood disturbance
- Increased tolerance -- takes more alcohol than before to get
- (l)This selective listing of dependence symptoms is offered as an
initial assessment procedure and not for the purpose of making a diagnosis.
For a diagnostic evaluation, refer your patients to a specialist or use
the diagnostic procedures outlined in the "Diagnostic and Statistical
Manual of Health Disorders, Fourth Edition (DSM-IV)."
- Ask the following questions:
- - Are there times when you are unable to stop drinking once you have
- - Does it take more drinks than before to get "high?"
- - Do you feel a strong urge to drink?
- - Do you change your plans so that you can have a drink?
- - Do you ever drink in the morning to relieve the shakes?
STEP III. ADVISE APPROPRIATE ACTION
State your medical concern:
- Be specific about your patient's drinking patterns and related health
- ASK: How do you feel about your drinking?
Advise to abstain or cut down:
- - evidence of alcohol dependence
- - history of repeated failed attempts to cut down
- - pregnant or trying to conceive
- - contraindicated medical condition or medication
- - drinking above recommended low-risk drinking amounts and no evidence
of alcohol dependence
Agree upon a plan of action
- ASK: Are you ready to try to cut down or abstain?
- Talk with patients who are ready to make a change in their drinking
about a specific plan of action.
For patients who are not alcohol dependent:
- Recommend low-risk consumption limits for your patient based upon the
low-risk drinking recommendations and your patient's health history (see
- Ask your patient to set a specific drinking goal: Are you ready to
set a drinking goal? Some patients choose to abstain for a period of time
or for good; others prefer to limit the amount they drink. What do you
think will work best for you?
- Provide patient education materials and tell your patient: It helps
to think about your reasons for wanting to cut down and examine what situations
trigger unhealthy drinking patterns. These materials will give you some
useful tips on how to maintain your drinking goal.
For patients with evidence of alcohol dependence:
- Refer for additional diagnostic evaluation or treatment. Procedures
for patient referral are as follows:
- - Involve your patient in making referral decisions.
- - Discuss available alcohol treatment services.
- - Schedule a referral appointment while the patient is in the office.
SOME PATIENT COUNSELING TIPS
- Use an empathic, nonconfrontational style.
- Offer your patient some choices about how to effect change.
- Emphasize your patient's responsibility for changing drinking behavior.
- Convey confidence in your patient's ability to change drinking behavior.
STEP IV. MONITOR PATIENT PROGRESS
Monitor patient progress in the same way you manage other chronic medical
problems, such as hypertension or diabetes. Recognize that behavior change
is an incremental process that often involves trial and error. Patient management
strategies include the following:
- Indicate that you (or your designated staff) are available to provide
ongoing assistance and support.
- Support your patient's efforts to cut down or abstain at each subsequent
- - reviewing progress to date
- - commending your patient for efforts made
- - reinforcing positive change
- - assessing continued motivation
- Consider scheduling a separate followup visit or telephone call, as
appropriate, if the patient needs additional support.
- Consider referring a selected patient whose counseling needs exceed
the services provided in a primary care setting.
For patients who have been advised to abstain or have been referred for
- Ask to receive periodic updates from the treatment specialist on your
patient's treatment plan and prognosis.
- Monitor symptoms of depression and anxiety. Such symptoms may occur,
but they often decrease or disappear after 2 to 3 weeks of abstinence.
- Monitor GGT levels, when appropriate, as a means of assessing alcohol
WHAT TO DO ABOUT PATIENTS WHO ARE NOT READY TO CHANGE
THEIR DRINKING BEHAVIOR
Do not be discouraged if patients are not ready to take action immediately.
Decisions to change behavior often involve fluctuating motivation and feelings
of ambivalence. By offering your advice, you have prompted your patients
to think more seriously about their drinking behavior. In many cases, continued
reinforcement is the key to a patient's decision to take action. Offer the
following guidance to patients who are not ready to take action:
- Restate your concern for your patient's health.
- Reinforce your willingness to help when the patient is ready.
- Continue to monitor alcohol use at subsequent office visits.
For patients who may be alcohol dependent, you may want to consider some
- Encourage your patient to consult an alcohol specialist.
- Ask your patient to discuss your recommendation with family members
and schedule a followup visit that includes family members/significant
- Recommend a trial period of abstinence, monitor for withdrawal symptoms,
and review progress in a followup visit.
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WHERE TO GO FOR ADDITIONAL INFORMATION
The National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Office of Scientific Affairs
6000 Executive Boulevard, Suite 409
Bethesda, MD 20892-7003
American Society of Addiction Medicine (ASAM)
460l North Park Avenue
Suite l0l, Upper Arcade
Chevy Chase, MD 208l5
National Council on Alcoholism and Drug Dependence (NCADD)
l2 West 2lst Street
New York, NY l00l0