Audit Romania Alcool

WHO/MSD/MSB/01.
6a Origina l: English Distribut ion: Genera l
Thomas F. Babor John C. Higgins-Biddle John B. Saunders Maristela G. Monteiro
AUDIT
The Alcohol Use Disorders Ident i f ic at ion Test

Guidelines for Use in Primary Care
Second Edition
W or l d Hea l t h Organ i zat i on Department o f M ental Health and S ub s tan c e Dependen c e
WHO/MSD/MSB/01.6a Origina l: English Distribut ion: Genera l
Thomas F. Babor John C. Higgins-Biddle John B. Saunders Maristela G. Monteiro
AUDIT
The Alcohol Use Disorders Ident i f ic at ion Test

Guidelines for Use in Primary Care
Second Edition
W or l d Hea l t h Organ i zat i on Department o f M ental Health and S ub s tan c e Dependen c e
I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Ab s t r ac t
Th is manua l i ntrodu c es the AUDIT, the A l c oho l Use D isorders Ident i f i c at i on Test , and descri bes how to use i t to i dent i fy persons w i th hazardous and harmfu l patterns of a l c oho l c onsumpt i on . The AUDIT was deve l oped by the Worl d Hea l th Organ i zat i on (WHO) as a si mp l e method of screen i ng for exc essive dri nk i ng and to assist i n bri ef assessment . It c an he l p i n i dent i fyi ng exc essive dri nk i ng as the c ause of the present i ng ill ness. It a lso provi des a framework for i ntervent i on to he l p hazardous and harmfu l dri nkers redu c e or c ease a lc oho l c onsumpt i on and thereby avo i d the harmfu l c onsequen c es of the ir dri nk i ng . The f irst ed i t i on of th is manua l was pub lished i n 1989 (Do c ument No . WHO / MNH/DAT/89 . 4) and was subsequent ly updated i n 1992 (WHO /PSA /92 . 4). Si n c e that t i me i t has en j oyed w i despread use by both hea l th workers and a l c oho l researc hers. W i th the grow i ng use of a l c oho l screen i ng and the i nternat i ona l popu l ari ty of the AUDIT, there was a need to revise the manua l to take i nto a cc ount advan c es i n researc h and c li n i c a l experi en c e . Th is manua l is wri tten pri marily for hea l th c are pra c t i t i oners, but other professi ona ls who en c ounter persons w i th a l c oho l-re l ated prob l ems may a lso f i nd i t usefu l . It is desi gned to be used i n c on j un c t i on w i th a c ompan i on do c ument that provi des c omp l ementary i nformat i on about early i ntervent i on pro c edures, ent i t l ed Bri ef Intervent i on for Hazardous and Harmfu l Dri nk i ng: A Manua l for Use i n Pri mary Care . Together these manua ls descri be a c omprehensive approa c h to screen i ng and bri ef i ntervent i on for a l c oho l-re l ated prob l ems i n pri mary hea l th c are .
Ac kno w l ed g em en t s
The revisi on and f i na lisat i on of th is do c ument were c oord i nated by Mariste l a Monte iro w i th te c hn i c a l assistan c e from V l ad i m ir Poznyak from the WHO Department of Menta l Hea l th and Substan c e Dependen c e , and Deborah Ta l am i n i , Un iversi ty of Conne c t i c ut . F i nan c i a l support for th is pub li c at i on was provi ded by the M i n istry of Hea l th and We l fare of Japan .
Worl d Hea l th Organ i zat i on 2001 Th is do c ument is not a forma l pub li c at i on of the Worl d Hea l th Organ i zat i on (WHO), and a ll ri ghts are reserved by the Organ i zat i on . The do c ument may, however, be free ly revi ewed , abstra c ted , reprodu c ed , and transl ated , i n part or i n who l e but not for sa l e or for use i n c on j un c t i on w i th c ommerc i a l purposes. Inqu iri es shou l d be addressed to the Department of Menta l Hea l th and Substan c e Dependen c e , Worl d Hea l th Organ i zat i on , CH-1211 Geneva 27 , Sw i tzerl and , wh ic h w ill be g l ad to provi de the l atest i nformat i on on any c hanges made to the text , p l ans for new ed i t i ons and the repri nts, reg i ona l adaptat i ons and transl at i ons that are a lready ava il ab l e . Authors a l one are responsi b l e for vi ew s expressed i n th is do c ument , wh i c h are not ne c essarily those of the Worl d Hea l th Organ i zat i on .
TA BLE O F C ON T E N TS
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Tab l e o f Co n t en t s
4 5 8 10 14 19 21 25 P urpo s e o f this M anual W hy Screen f or A lc ohol U s e ? The Context o f A lc ohol Screening Development and Validation o f the A UD IT A dminis tration Guideline s Sc oring and I nterpretation Ho w to Help P atient s Programme I mplementation A ppendix 28 30 32 33 34 35 A . R e s earc h Guideline s f or the A UD IT B . S ugge s ted F ormat f or A UD IT S elf-R eport Q ue s tionnaire C . Tran slation and A daptation to S pe cific L anguage s, Culture s and S tandard s D . Clinic al Screening Pro c edure s E . Training M aterials f or A UD IT R e f eren c e s
Purpo se o f t hi s Manual
h is manua l i ntrodu c es the AUDIT, the A l c oho l Use D isorders Ident i f i c at i on Test , and describes how to use it to identify persons w i th hazardous and harmfu l patterns of a l c oho l c onsumpt i on . The AUDIT was deve l oped by the Worl d Hea l th Organ i zat i on (WHO) as a si mp l e method of screen i ng for exc essive dri nk i ng and to assist i n bri ef assessment . 1 , 2 It c an he l p i dent i fy exc essive dri nk i ng as the c ause of the present i ng ill ness. It provi des a framework for i ntervent i on to he l p risky dri nkers redu c e or c ease a l c oho l c onsumpt i on and thereby avo i d the harmfu l c onsequen c es of the ir dri nk i ng . The AUDIT a lso he l ps to i dent i fy a l c oho l dependen c e and some spe c i f i c c onsequen c es of harmfu l dri nk i ng . It is part i c u l arly desi gned for hea l th c are pra c t i t i oners and a range of hea l th sett i ngs, but w i th su i tab l e i nstru ct i ons i t c an be se l f-adm i n istered or used by non-hea l th professi ona ls. To th is end , the manua l w ill descri be: Reasons to ask about a l c oho l c onsumpt i on The c ontext of a l c oho l screen i ng Deve l opment and va li dat i on of the AUDIT The AUDIT quest i ons and how to use them Sc ori ng and i nterpretat i on How to c ondu c t a c li n i c a l screen i ng exam i nat i on How to he l p pat i ents who screen posi t ive How to i mp l ement a screen i ng programme
The append i c es to th is manua l c onta i n add i t i ona l i nformat i on usefu l to pra c t it i oners and researc hers. F urther researc h on the re li ab ili ty, va li d i ty, and i mp l ementat i on of screen i ng w i th the AUDIT is suggested usi ng gu i de li nes out li ned i n Append ix A . Append ix B c onta i ns an examp l e of the AUDIT i n a se l f-report quest i onna ire format . Append ix C provi des gu i de li nes for the transl at i on and adaptat i on of the AUDIT. Append ix D descri bes c li n i c a l screen i ng pro c edures usi ng a physi c a l exam , l aboratory tests and med i c a l h istory data . Append ix E lists i nformat i on about ava il ab l e tra i n i ng materi a ls.
WH Y S C REE N F O R A L C OHO L U S E ?
I5
W hy Screen f o r Al co ho l Use?
here are many forms of exc essive dri nk i ng that c ause substant i a l risk or harm to the i nd ivi dua l . They i n c l ude h i gh l eve l dri nk i ng ea c h day, repeated ep isodes of dri nk i ng to i ntoxi c at i on , dri nk i ng that is a c tua lly c ausi ng physi c a l or menta l harm , and dri nk i ng that has resu l ted i n the person be c om i ng dependent or add i c ted to a l c oho l . Exc essive dri nk i ng c auses ill ness and d istress to the dri nker and h is or her fam ily and fri ends. It is a ma j or c ause of breakdown i n re l at i onsh i ps, trauma , hosp i ta li zat i on , prol onged d isab ili ty and early death . A l c oho l-re l ated prob l ems represent an i mmense e c onom i c l oss to many c ommun i t i es around the worl d . AUDIT was deve l oped to screen for exc essive dri nk i ng and i n part i c u l ar to he l p pra c t i t i oners i dent i fy peop l e who wou l d benef i t from redu c i ng or c easi ng dri nk i ng . The ma j ori ty of exc essive dri nkers are und i agnosed . Often they present w i th symptoms or prob l ems that wou l d not norma lly be li nked to the ir dri nk i ng . The AUDIT w ill he l p the pra c t it i oner i dent i fy whether the person has hazardous (or risky) dri nk i ng , harmfu l dri nk i ng , or a l c oho l dependen c e .
Harmfu l use refers to a l c oho l c onsumpt i on that resu l ts i n c onsequen c es to physi c a l and menta l hea l th . Some wou l d a lso c onsi der so c i a l c onsequen c es among the harms c aused by a l c oho l 3 , 4 . A l c oho l dependen c e is a c l uster of behavi oura l , c ogn i t ive , and physi o l og i c a l phenomena that may deve l op after repeated a l c oho l use 4 . Typ i c a lly, these phenomena i n c l ude a strong desire to c onsume a l c oho l , i mpa ired c ontro l over i ts use , persistent dri nk i ng desp i te harmfu l c onsequen c es, a h i gher pri ori ty g iven to dri nk i ng than to other a c t ivi t i es and ob li gat i ons, i n creased a l c oho l to l eran c e , and a physi c a l w i thdrawa l rea c t i on when a l c oho l use is d isc ont i nued .
A l c oho l is i mp li c ated i n a w i de vari ety of d iseases, d isorders, and i n j uri es, as we ll as many so c i a l and l ega l prob l ems5 , 6 , 7 . It is a ma j or c ause of c an c er of the mouth , esophagus, and l arynx. Liver cirrhosis and pan creat i t is often resu l t from l ong-term , exc essive c onsumpt i on . A l c oho l c auses harm to fetuses i n women who are pregnant . Moreover, mu c h more c ommon med i c a l c ond i t i ons, su c h as hypertensi on , gastri t is, d i abetes, and some forms of stroke are li ke ly to be aggravated even by o cc asi ona l and short-term a l c oho l c onsumpt i on , as are menta l d isorders su c h as depressi on . Automob il e and pedestri an i n j uri es, fa lls, and work-re l ated harm frequent ly resu l t from exc essive a l c oho l c onsumpt i on . The risks re l ated to a l c oho l are li nked to the pattern of dri nk i ng and the amount of c onsumpt i on 5 . Wh il e persons w i th a l c oho l
Hazardous dri nk i ng 3 is a pattern of a l c oho l c onsumpt i on that i n creases the risk of harmfu l c onsequen c es for the user or others. Hazardous dri nk i ng patterns are of pub li c hea l th si gn i f i c an c e desp i te the absen c e of any c urrent d isorder i n the i nd ivi dua l user.
dependen c e are most li ke ly to i n c ur h i gh l eve ls of harm , the bu l k of harm asso ciated w ith a lc oho l o cc urs among peop l e who are not dependent , i f on ly be c ause there are so many of them 8 . Therefore , the i dent i f i c at i on of dri nkers w i th vari ous types and degrees of at-risk a lc oho l c onsumpt i on has great potent i a l to redu c e a ll types of a l c oho l-re l ated harm . F i gure 1 ill ustrates the l arge vari ety of hea l th prob l ems asso c i ated w i th a l c oho l use . A l though many of these med i c a l c onsequen c es tend to be c on c entrated i n persons w i th severe a l c oho l dependen c e , even the use of a l c oho l i n the range of 20-40 grams of abso l ute a l c oho l per day is a risk fa c tor for a cc i dents, i n j uri es, and many so c i a l prob l ems5 , 6 . Many fa c tors c ontri bute to the deve l opment of a l c oho l-re l ated prob l ems. Ignoran c e of dri nk i ng li m i ts and of the risks asso c i ated w i th exc essive a l c oho l c onsumpt i on are ma j or fa c tors. So c i a l and environmenta l i nf l uen c es, su c h as c ustoms and att i tudes that favor heavy dri nk i ng , a lso p l ay i mportant ro l es. Of utmost i mportan c e for screen i ng , however, is the fa c t that peop l e who are not dependent on a l c oho l may stop or redu c e the ir a l c oho l c onsumpt i on w i th appropri ate assistan c e and effort . On c e dependen c e has deve l oped , c essat i on of a l c oho l c onsumpt i on is more d i ff i c u l t and often requ ires spe c i a li zed treatment . A l though not a ll hazardous dri nkers be c ome dependent , no one deve l ops a l c oho l dependen c e w i thout havi ng engaged for some t i me
i n hazardous a l c oho l use . G iven these fa c tors, the need for screen i ng be c omes apparent . Screen i ng for a l c oho l c onsumpt i on among pat i ents i n pri mary c are c arri es many potent i a l benef i ts. It provi des an opportun i ty to edu c ate pat i ents about l ow-risk c onsumpt i on l eve ls and the risks of exc essive a l c oho l use . Informat i on about the amount and frequen cy of a l c oho l c onsumpt i on may i nform the d i agnosis of the pat i ents present i ng c ond i t i on , and i t may a l ert c li n i c i ans to the need to advise pat i ents whose a l c oho l c onsumpt i on m i ght adverse ly affe c t the ir use of med i c at i ons and other aspe c ts of the ir treatment . Screen i ng a lso offers the opportun i ty for pra c t i t i oners to take preventat ive measures that have proven effe c t ive i n redu c i ng a l c oho l-re l ated risks.
WH Y S C REE N F O R A L C OHO L U S E ?
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Fi g ur e 1
E ff e c t s o f H i g h - R i s k D r i nk i n g
Aggressive , irrat i ona l behavi our. Arguments. V i o l en c e . Depressi on . Nervousness. Can c er of throat and mouth . Frequent c o l ds. Redu c ed resistan c e to i nfe c t i on . In creased risk of pneumon i a . Liver damage . V i tam i n def i c i en cy. Bl eed i ng . Severe i nf l ammat i on of the stoma c h . Vom i t i ng . D i arrhea . Ma l nutri t i on . Weakness of heart musc l e . Heart fa il ure . Anem i a . Impa ired b l ood c l ott i ng . Breast c an c er. A l c oho l dependen c e . Memory l oss.
Premature ag i ng . Dri nker's nose .
Tremb li ng hands. T i ng li ng f i ngers. Numbness. P a i nfu l nerves. U l c er.
Inf l ammat i on of the pan creas.
Impa ired sensat i on l ead i ng to fa lls.
In men: Impa ired sexua l performan c e . In women: Risk of g ivi ng b irth to deformed , retarded bab i es or l ow b irth we i ght bab i es.
Numb , t i ng li ng toes. P a i nfu l nerves.
H i gh-risk dri nk i ng may l ead to so c i a l , l ega l , med i c a l , domest i c , j ob and f i nan c i a l prob l ems. It may a lso c ut your li fespan and l ead to a cc i dents and death from drunken drivi ng .
T he Co n t ex t o f Al co ho l Screeni ng
h il e th is manua l fo c uses on usi ng the AUDIT to screen for a l c oho l c onsumpt i on and re l ated risks i n pri mary c are med i c a l sett i ngs, the AUDIT c an be effe ct ive ly app li ed i n many other c ontexts as we ll . In many c ases pro c edures have a lready been deve l oped and used i n these sett i ngs. Box 1 summari zes i nformat i on about the sett i ngs, screen i ng personne l , and target groups c onsi dered appropri ate for a screening programme using the AUDIT. Murray9 has argued that screen i ng m i ght be c ondu c ted prof i tab ly w i th : genera l hosp i ta l pat i ents, espe c i a lly those w i th d isorders known to be asso c i ated w i th a l c oho l dependen c e (e . g ., pan creat i t is, c irrhosis, gastri t is, tuberc u l osis, neuro l og i c a l d isorders, c ard i omyopathy); persons who are depressed or who attempt su i c i de; other psyc h i atri c pat i ents; pat i ents attend i ng c asua l ty and emergen cy servi c es; pat i ents attend i ng genera l pra c t i t i oners; vagrants; prisoners; and those c i ted for l ega l offen c es c onne c ted w i th dri nk i ng (e . g ., drivi ng wh il e i ntoxic ated , pub li c i ntoxi c at i on).
To these shou l d be added groups c onsi dered by a WHO Expert Comm i ttee 7 to be at h i gh risk of deve l op i ng a l c oho l-re l ated prob l ems: m i dd l e-aged ma l es, ado l esc ents, m i grant workers, and c erta i n o cc upat i ona l groups (su c h as busi ness exe c ut ives, enterta i ners, sex workers, pub li c ans, and seamen). The nature of the risk d i ffers by age , gender, dri nk i ng c ontext , and dri nk i ng pattern , w i th so c i o c u l tura l fa c tors p l ayi ng an i mportant ro l e i n the def i n i t i on and expressi on of a l c oho l-re l ated prob l ems6 .
T H E C ON T E X T O F A L C OHO L S C REE N I NG
I9
Box 1
Pe r s o nne l , S e tt i n g s an d G r o u p s C o n s i d e r e d A pp r op r i a t e f o r a S c r een i n g P r og r a mm e U s i n g t he AU D I T
S e tt i n g
Pri mary c are c li n i c Emergen cy room
Ta r g e t G r o u p
Med i c a l pat i ents A cc i dent vi c t i ms, Intoxi c ated pat i ents, trauma vi c t i ms Med i c a l pat i ents P at i ents w i th hypertensi on , heart d isease , gatro i ntest i na l or neuro l og i c a l d isorders Psyc h i atri c pat i ents, part i c u l arly those who are su i c i da l DW I offenders vi o l ent cri m i na ls P ersons demonstrat i ng i mpa ired so c i a l or o cc upat i ona l fun c t i on i ng (e . g . mari ta l d isc ord , c h il d neg l e c t , et c .) En listed men and off i c ers Workers, espe c i a lly those havi ng prob l ems w i th produ c t ivi ty, absentee ism or a cc i dents
Sc r ee n i n g Pe r s o nn e l
Nurse , so c i a l worker P hysi c i an , nurse , or staff
P hysi c i an s Room Surgery Genera l Hosp i ta l wards Out-pat i ent c li n i c
Genera l pra c t i t i oner, fam ily physi c i an or staff Intern ist , staff
Psyc h i atri c hosp i ta l
Psyc h i atrist , staff
Court , j a il , prison Other hea l th-re l ated fa c ili t i es
Off i c ers, Counse ll ors Hea l th and human servi c e workers
M ili tary Servi c es Work p l a c e Emp l oyee assistan c e Programme
Med i cs Emp l oyee assistan c e staff
10
Dev el op men t and Vali d a t i o n o f t he AUDIT
he AUDIT was deve l oped and eva l uated over a peri od of two de c ades, and i t has been found to provi de an a cc urate measure of risk a cross gender, age , and c u l tures1 , 2 , 10 . Box 2 descri bes the c on c eptua l doma i ns and i tem c ontent of the AUDIT, wh i c h c onsists of 10 quest i ons about re c ent a l c oho l use , a l c oho l dependen c e symptoms, and a l c oho l-re l ated prob l ems. A s the f irst screen i ng test desi gned spe c i fi c a lly for use i n pri mary c are sett i ngs, the AUDIT has the fo ll ow i ng advantages: Cross-nat i ona l standard i zat i on: the AUDIT was va li dated on pri mary hea l th c are pat i ents i n six c ountri es1 , 2 . It is the on ly screen i ng test spe c i f i c a lly desi gned for i nternat i ona l use; Ident i f i es hazardous and harmfu l a l c oho l use , as we ll as possi b l e dependen c e; Bri ef , rap i d , and f l exi b l e; Desi gned for pri mary hea l th c are workers; Consistent w ith I CD-10 definitions of alc ohol dependenc e and harmful alc ohol use3,4; F o c uses on re c ent a l c oho l use . In 1982 the Worl d Hea l th Organ i zat i on asked an i nternat i ona l group of i nvest i gators to deve l op a si mp l e screen i ng i nstrument 2 . Its purpose was to i dent i fy persons w i th early a l c oho l prob l ems usi ng pro c edures that were su i tab l e for hea l th systems in both developing and developed c ountries. The i nvest i gators revi ewed a vari ety of se l f-report , l aboratory, and c li n i c a l pro c edures that had been used for th is purpose i n d i fferent c ountri es. They then i n i t i ated a cross-nat i ona l study to se l e c t the best features of these vari ous nat i ona l approa c hes to screen i ng 1 .
Th is c omparat ive f i e l d study was c ondu c ted i n six c ountri es (Norway, Austra li a , Kenya , Bu l gari a , Mexi c o , and the Un i ted States of Ameri c a). The method c onsisted of se l e c t i ng items that best d ist i ngu ished l ow-risk dri nkers from those w ith harmfu l dri nk i ng . Un li ke previ ous screen i ng tests, the new i nstrument was i ntended for the early i dent if ic at i on of hazardous and harmfu l dri nk i ng as we ll as a lc oho l dependen c e (a lc oho lism). Nearly 2000 pat i ents were re cru ited from a vari ety of hea lth c are fa cilit i es, i n cl ud i ng spe ci a lized a lc oho l treatment c enters. Sixty-four perc ent were c urrent dri nkers, 25% of whom were d i agnosed as a lc oho l dependent . P art i c i pants were g iven a physi c a l exam inat i on , i n c l ud i ng a b l ood test for standard b l ood markers of a l c oho lism , as we ll as an extensive i ntervi ew assessi ng demograph i c c hara c terist i cs, med i c a l h istory, hea l th c omp l a i nts, use of a l c oho l and drugs, psyc ho l og i c a l rea c t i ons to a l c oho l , prob l ems asso c i ated w i th dri nk i ng , and fam ily h istory of a l c oho l prob l ems. Items were se l e c ted for the AUDIT from th is poo l of quest i ons pri marily on the basis of c orre l at i ons w i th da ily a l c oho l i ntake , frequen cy of c onsum i ng six or more dri nks per dri nk i ng ep isode , and the ir ab ili ty to d iscri m i nate hazardous and harmfu l dri nkers. Items were a lso c hosen on the basis of fa c e va li d i ty, c li n i c a l re l evan c e , and c overage of re l evant c on c eptua l doma i ns (i . e ., a lc oho l use , a lc oho l dependen c e , and adverse c onsequen c es of dri nk i ng). Fi na lly, spe ci a l attent i on i n i tem se l e c t i on was g iven to gender appropri ateness and cross-nat i ona l genera li zab ili ty.
D E V EL O P M E N T AND VA L I DATI ON O F T H E AUD IT
I 11
Box 2
D o m a i n s an d I t e m C o n t en t o f t he AU D I T
Do m a i n s
Hazardous A l c oho l Use Dependen c e Symptoms
Ques t i on Number
1 2 3 4 5 6 7 8 9 10
I t em Con t en t
Frequen cy of dri nk i ng Typ i c a l quant i ty Frequen cy of heavy dri nk i ng Impa ired c ontro l over dri nk i ng In creased sa li en c e of dri nk i ng Morn i ng dri nk i ng Gu il t after dri nk i ng Bl a c kouts A l c oho l-re l ated i n j uri es Others c on c erned about dri nk i ng ment samp l es1 , a c ut-off va l ue of 8 po i nts yi e l ded sensi t ivi t i es for the AUDIT for various i nd i c es of prob l emat i c dri nk i ng that were genera lly i n the m i d 0 . 90 s. Spe c i f i c i t i es a cross c ountri es and a cross cri teri a averaged i n the 0 . 80 s. The AUDIT d i ffers from other se l f-report screen i ng tests i n that i t was based on data c o ll e c ted from a l arge mu l t i nat i ona l samp l e , used an exp li c i t c on c eptua lstat ist i c a l rat i ona l e for i tem se l e c t i on , emphasi zes i dent i f i c at i on of hazardous dri nk i ng rather than l ong-term dependen c e and adverse dri nk i ng c onsequen c es, and fo c uses pri marily on symptoms o cc urri ng duri ng the re c ent past rather than ever.
Harmfu l A l c oho l Use
Sensi t ivi t i es and spe c i f i c i t i es of the se l e c ted test i tems were c omputed for mu l t i p l e cri teri a (i . e ., average da ily a lc oho l c onsumpt i on , re c urrent i ntoxi c at i on , presen c e of at l east one dependen c e symptom , d i agnosis of a l c oho l abuse or dependen c e , and se l fperc ept i on of a dri nk i ng prob l em). Vari ous c ut-off po i nts i n tota l sc ores were c onsi dered to i dent i fy the va l ue w i th opt i ma l sensi t ivi ty (perc entage of posi t ive c ases that the test c orre c t ly i dent i f i ed) and spe c i f i c i ty (perc entage of negat ive c ases that the test c orre c t ly i dent i f i ed) to d ist i ngu ish hazardous and harmfu l a l c oho l use . In add i t i on , va li d i ty was a lso c omputed aga i nst a c omposi te d i agnosis of harmfu l use and dependen c e . In the test deve l op-
12
On c e the AUDIT had been pub lished , the deve l opers re c ommended add i t i ona l va lidat i on researc h . In response to th is request , a l arge number of stud i es have been c ondu c ted to eva l uate i ts va li d i ty and re li ab ili ty i n d i fferent c li n i c a l and c ommun i ty samp l es throughout the worl d 10 . At the re c ommended c ut-off of 8 , most stud i es have found very favorab l e sensi t ivi ty and usua lly l ower, but st ill a cc eptab l e , spe c if i c i ty, for c urrent I CD-10 a l c oho l use d isorders10 , 11 , 12 as we ll as the risk of future harm 12 . Neverthe l ess, i mprovements i n dete c t i on have been a c h i eved i n some c ases by l oweri ng or ra isi ng the c ut-off sc ore by one or two po i nts, depend i ng on the popu l at i on and the purpose of the screen i ng programme 11 , 12 . A variety of subpopu lations have been studi ed , i n cl ud i ng pri mary c are pat i ents 13 , 14 , 15 , emergen cy room c ases11 , drug users16 , the unemp l oyed 17 , un iversi ty students18 , e l derly hosp i ta l pat i ents19 , and persons of l ow so c i o-e c onom i c status20 . The AUDIT has been found to provi de good d iscri m inat i on i n a vari ety of sett i ngs where these popu l at i ons are en c ountered . A re c ent systemat i c revi ew 21 of the li terature has c on c l uded that the AUDIT is the best screen i ng i nstrument for the who l e range of a l c oho l prob l ems i n pri mary c are , as c ompared to other quest i onna ires su c h as the C A GE and the M AST. Cu l tura l appropri ateness and crossnat i ona l app lic ab ili ty were i mportant c onsi derat i ons i n the deve l opment of the AUDIT1 , 2 . Researc h has been c ondu c ted i n a w i de vari ety of c ountri es and
c u l tures11 , 12 , 13 , 15 , 19 , 22 , 23 , 24 , suggest i ng that the AUDIT has fu l f ill ed i ts prom ise as an i nternat i ona l screen i ng test . A l though evi den c e on women is somewhat li m i ted 11 , 12 , 24 , the AUDIT seems equa lly appropri ate for ma l es and fema l es. The effe c t of age has not been systemat i c a lly ana lyzed as a possi b l e i nf l uen c e on the AUDIT, but one study19 found l ow sensit ivi ty but h i gh spe c i f i c i ty i n pat i ents above age 65 . The AUDIT has proven to be a cc urate i n dete c t i ng a l c oho l dependen c e i n un iversi ty students18 . In c omparison to other screen i ng tests, the AUDIT has been found to perform equa lly we ll or at a h i gher degree of a cc ura cy10 , 11 , 25 , 26 a cross a w i de vari ety of criteri on measures. Bohn , et a l . 27 found a strong c orre l at i on between the AUDIT and the M AST (r= . 88) for both ma l es and fema l es, and c orre l at i ons of . 47 and . 46 for ma l es and fema l es, respe c t ive ly, on a c overt c ontent a l c oho lism screen i ng test . A h i gh c orre l at i on c oeff i c i ent (. 78) was a lso found between the AUDIT and the C A GE i n ambu l atory c are pat i ents26 . AUDIT sc ores were found to c orre l ate we ll w i th measures of dri nk i ng c onsequen c es, att i tudes toward dri nk i ng , vu l nerab ili ty to a lc oho l dependen c e , negat ive mood states after dri nk i ng , and reasons for dri nk i ng 27 . It appears that the tota l sc ore on the AUDIT ref l e c ts the extent of a l c oho l i nvo lvement a l ong a broad c ont i nuum of severi ty. Two stud i es have c onsi dered the re l at i on between AUDIT sc ores and future i nd i c ators of a l c oho l-re l ated prob l ems and more
D E V EL O P M E N T AND VA L I DATI ON O F T H E AUD IT
I 13
g loba l life fun c t ion ing . In one study17 , the li ke li hood of rema i n i ng unemp l oyed over a two year peri od was 1 . 6 t i mes h i gher for i nd ivi dua ls w i th sc ores of 8 or more on the AUDIT than for c omparab l e persons w i th l ower sc ores. In another study28 , AUDIT sc ores of ambu l atory c are pat i ents pred i c ted future o cc urren c e of a physi c a l d isorder, as we ll as so c i a l prob l ems re l ated to dri nk i ng . AUDIT sc ores a lso pred i c ted hea l th c are ut ili zat i on and future risk of engag i ng i n hazardous dri nk i ng 28 . Severa l stud i es have reported on the re liab ili ty of the AUDIT18 , 26 , 29 . The resu l ts i nd ic ate h i gh i nterna l c onsisten cy, suggesti ng that the AUDIT is measuri ng a si ng l e c onstru c t i n a re li ab l e fash i on . A test-retest re li ab ili ty study29 i nd i c ated h i gh re li ab ili ty (r= . 86) i n a samp l e c onsist i ng of non-hazardous dri nkers, c o c a i ne abusers, and a l c oho li cs. Another methodo l og i c a l study was c ondu c ted i n part to i nvest i gate the effe c t of quest i on orderi ng and word i ng c hanges on preva l en c e est i mates and i nterna l c onsisten cy re li ab ili ty22 . Changes i n quest i on orderi ng and word i ng d i d not affe c t the AUDIT sc ores, suggest i ng that w i th i n li m i ts, researc hers c an exerc ise some f l exi b ili ty i n mod i fyi ng the order and word i ng of the AUDIT i tems. W i th i n creasi ng evi den c e of the re li ab ili ty and va li d i ty of the AUDIT, stud i es have been c ondu c ted usi ng the test as a preva l en c e measure . Lapham , et a l . 23 used i t to est i mate preva l en c e of a l c oho l use d isorders i n emergen cy rooms (ERs) of three reg i ona l hosp i ta ls i n Tha il and .
It was c on c l uded that the ER is an i dea l sett i ng for i mp l ement i ng a lc oho l screeni ng w i th the AUDIT. Si m il arly, Pi cc i ne lli , et a l . 15 eva l uated the AUDIT as a screen i ng too l for hazardous a lc oho l i ntake i n pri mary c are c li n i cs i n Ita ly. AUDIT performed we ll i n i dent i fyi ng a lc oho l-re l ated d isorders as we ll as hazardous use . Ivis, et a l . 22 i n c orporated the AUDIT i nto a genera l popu l at i on te l ephone survey i n Ontari o , Canada . Si n c e the AUDIT Users Manua l was f irst pub lished i n 1989 30 , the test has fu l f ill ed many of the expe c tat i ons that i nsp ired i ts deve l opment . Its re li ab ili ty and va li d i ty have been estab lished i n researc h c ondu c ted i n a vari ety of sett i ngs and i n many d i fferent nat i ons. It has been transl ated i nto many l anguages, i n c l ud i ng Turk ish , Greek , H i nd i , German , Dut c h , P o lish , Japanese , Fren c h , P ortuguese , Span ish , Dan ish , F l em ish , Bu l gari an , Ch i nese , Ita li an , and N i geri an d i a l e c ts. Tra i n i ng programmes have been deve l oped to fa c ili tate i ts use by physic i ans and other hea l th c are provi ders31 , 32 (see Append ix E). It has been used i n pri mary c are researc h and i n ep i dem i o l og i c a l stud i es for the est i mat i on of preva l en c e i n the genera l popu l at i on as we ll as spec i f i c i nst i tut i ona l groups (e . g ., hosp i ta l pat i ents, pri mary c are pat i ents). Desp i te the h i gh l eve l of researc h a c t ivi ty on the AUDIT, further researc h is needed , espec i a lly i n the l ess deve l oped c ountri es. Append ix A provi des gu i de li nes for c ont i nued researc h on the AUDIT.
14
Ad m i ni s tra t i o n Gui d eli nes
he AUDIT c an be used i n a vari ety of ways to assess pat i ents a l c oho l use , but programmes to i mp l ement i t shou l d f irst set gu i de li nes that c onsi der the pat i ent s c irc umstan c es and c apa c i t i es. Add i t i ona lly, c are must be taken to te ll pat i ents why quest i ons about a l c oho l use are be i ng asked and to provi de i nformat i on they need to make appropri ate responses. A de c isi on must be made whether to adm i n ister the AUDIT ora lly or as a wri tten , se l f-report quest i onna ire . F i na lly, c onsi derat i on must be g iven to usi ng sk i p-outs to shorten the screen i ng for greater eff i c i en cy. Th is se c t i on re c ommends gu i de li nes on su c h issues of adm i n istrat i on .
The pat i ent is not i ntoxi c ated or i n need of emergen cy c are at the t i me; The purpose of the screen i ng be c l early stated i n terms of i ts re l evan c e to the pat i ent s hea l th status; The i nformat i on pat i ents need to understand the quest i ons and respond a cc urate ly be provi ded; and A ssuran c e is g iven that the pat i ent s responses w ill rema i n c onf i dent i a l . Hea l th workers shou l d try to estab lish these c ond i t i ons before the AUDIT is g iven . When these c ond i t i ons are not present or when a pat i ent is resistant , the C li n i c a l Screen i ng Pro c edures (d isc ussed i n Append ix D) may provi de an a l ternat ive c ourse of a c t i on . Choose the best possi b l e c irc umstan c e for adm i n isteri ng the AUDIT. F or pat i ents requ iri ng emergen cy treatment or i n great pa i n , i t is best to wa i t unt il the ir med i c a l c ond i t i on has stab ili zed and they have be c ome a cc ustomed to the hea l th sett i ng where adm i n istrat i on of the AUDIT is to take p l a c e . Look for si gns of a l c oho l or drug i ntoxi c at i on . P at i ents who have a l c oho l on the ir breath or who appear i ntoxic ated may be unre li ab l e respondents. Consi der screen i ng at a l ater t i me . If th is is not possi b l e , make note of these f i ndi ngs on the pat i ent's re c ord . When presented i n a med i c a l c ontext w i th genu i ne c on c ern for the pat i ent s we ll be i ng , pat i ents are a l most a l ways open and responsive to the AUDIT quest i ons. Moreover, most pat i ents ans wer the quest i ons honest ly. Even when exc essive
C o n s i d e r i n g t h e Pa t i e n t
A ll pat i ents shou l d be screened for a l c oho l use , preferab ly annua lly. The AUDIT c an be adm i n istered separate ly or c omb i ned w i th other quest i ons as part of a genera l hea l th i ntervi ew, a li festyl e quest i onna ire , or med i c a l h istory. If hea l th workers screen on ly those they c onsi der most li ke ly to have a dri nk i ng prob l em , the ma j ori ty of pat i ents who dri nk exc essive ly w ill be m issed . However, i t is i mportant to c onsi der the c ond i t i on of the pat i ents when ask i ng them to ans wer quest i ons about a l c oho l use . To i n crease the pat i ent s re c ept ivi ty to the quest i ons and the a cc ura cy of respond i ng , i t is i mportant that: The i ntervi ewer (or presenter of the survey) be fri end ly and non-threaten i ng;
ADM I N IST R ATI ON GU I D EL I N E S
I 15
dri nkers underest i mate the ir c onsumpt i on , they often qua li fy on the AUDIT sc ori ng system as posi t ive for a l c oho l risk .
I n t r od u c i n g t h e AU D I T
Whether the AUDIT is used as an ora l i ntervi ew or a wri tten quest i onna ire , i t is re c ommended that an exp l anat i on be g iven to pat i ents of the c ontent of the quest i ons, the purpose for ask i ng them , and the need for a cc urate ans wers. The fo ll ow i ng are ill ustrat ive i ntrodu c t i ons for ora l de livery and wri tten quest i onna ires:
Now I am go i ng to ask you some quest i ons about your use of a l c oho li c beverages duri ng the past year. Be c ause a l c oho l use c an affe c t many areas of hea l th (and may i nterfere w i th c erta i n med i c at i ons), i t is i mportant for us to know how mu c h you usua lly dri nk and whether you have experi en c ed any prob l ems w i th your dri nk i ng . Pl ease try to be as honest and as a cc urate as you c an be . A s part of our hea l th servi c e i t is i mportant to exam i ne li festyl e issues li ke ly to affe c t the hea l th of our pat i ents. Th is i nformat i on w ill assist i n g ivi ng you the best treatment and h i ghest possi b l e standard of c are . Therefore , we ask that you c omp l ete th is quest i onna ire that asks about your use of a l c oho li c beverages duri ng the past year. Pl ease ans wer as a cc urate ly and honest ly as possi b l e . Your hea l th worker w ill d isc uss th is issue w i th you . A ll i nformat i on w ill be treated i n stri c t c onf i den c e .
Th is statement shou l d be fo ll owed by a descri pt i on of the types of a l c oho li c beverages typ i c a lly c onsumed i n the c ountry or reg i on where the pat i ent lives (e . g ., By a l c oho li c beverages we mean your use of w i ne , beer, vodka , sherry, et c . ) If ne c essary, i n c l ude a descri pt i on of beverages that may not be c onsi dered a l c oho li c , (e . g . c i der, l ow a l c oho l beer, et c .). W i th pat i ents whose a l c oho l c onsumpt i on is proh i b i ted by l aw, c u l ture , or re li g i on (e . g ., youths, observant Muslims), a c know ledgment of su c h proh i b i t i on and en c ouragement of c andor may be needed . F or examp l e , I understand others may th i nk you shou l d not dri nk a l c oho l at a ll , but i t is i mportant i n assessi ng your hea l th to know what you a c tua lly do . P at i ent i nstru c t i ons shou l d a lso c l ari fy the mean i ng of a standard dri nk . Quest i ons 2 and 3 of AUDIT ask about dri nks c onsumed . The mean i ng of th is word d i ffers from one nat i on and c u l ture to another. It is i mportant therefore to ment i on the most c ommon a l c oho li c beverages li ke ly to be c onsumed and how mu c h of ea c h c onst itutes a drink (approximate ly 10 grams of pure ethano l). F or examp l e , one bott l e of beer (330 m l at 5 % ethano l), a g l ass of w i ne (140 m l at 12 % ethano l), and a shot of sp iri ts (40 m l at 40 % ethano l) represent a standard dri nk of about 13 g of ethano l . Si n c e the types and amounts of a l c oho li c dri nks w ill vary a cc ord i ng to c u l ture and c ustom , the a l c oho l c ontent of typ i c a l servi ngs of beer, w i ne and sp iri ts must be determ i ned to adapt the AUDIT to part i c u l ar sett i ngs. See Append ix C .
16
O r a l A d m i n i s t r a t i o n v s. S e l f -r e po r t Q u e s t i o nn a i r e
The AUDIT may be adm i n istered e i ther as an ora l i ntervi ew or as a se l f-report quest i onna ire . Ea c h method c arri es i ts own advantages and d isadvantages that must be we i ghed i n li ght of t i me and c ost c onstra i nts. The re l at ive meri ts of usi ng the AUDIT as an i ntervi ew vs. the se l f-report quest i onna ire are summari zed i n Box 3 . The c ogn i t ive c apa c i t i es (li tera cy, forgetfu lness) and l eve l of c ooperat i on (defensiveness) of the pat i ent shou l d be c onsi dered . If the expe c tat i on is that pri mary c are provi ders w ill manage a ll the c are that pat i ents w ill re c e ive for the ir a l c oho l probl ems, an i ntervi ew may have advantages. However, i f the provi ders responsi b ili ty w ill be li m i ted to offeri ng bri ef advi c e to pat i ents who screen posi t ive and referri ng more severe c ases to other servi c es, the questionnaire method may be preferable .
Whatever de cision is made , it must be c onsistent w ith implementation plans to establish a c omprehensive screening programme . The AUDIT quest i ons and responses are presented i n Box 4 i n a format suggested for an ora l i ntervi ew. Append ix B g ives an examp l e of the se l f-report quest i onna ire . Adaptat i on shou l d be made to needs of the part ic u l ar screen i ng programme as we ll as the a lc oho lic beverages most c ommon ly c onsumed i n that so ci ety. Append ix C provi des gu i de li nes for transl at i on and adaptat i on to nat i ona l and l o c a l c ond i t i ons. If the AUDIT is administered as an interview, i t is i mportant to read the quest i ons as wri tten and i n the order i nd i c ated . By fo ll ow i ng the exa c t word i ng , better c omparab ili ty w ill be obta i ned between your resu l ts and those obta i ned by other i ntervi ewers. Most of the quest i ons i n the AUDIT are phrased i n terms of how
B ox 3
A dv an t a g e s o f D i ff e r en t A pp r o a c he s t o AU D I T A d m i n i s tr a t i o n
Q u e s t i o nn a i r e
Takes l ess t i me Easy to adm i n ister Su i tab l e for c omputer adm i n istrat i on and sc ori ng May produ c e more a cc urate ans wers A ll ow s seam l ess feedba c k to pat i ent and i n i t i at i on of bri ef advi c e
I n t e r v i ew
A ll ow s c l ari f i c at i on of amb i guous ans wers Can be adm i n istered to pat i ents w i th poor read i ng sk ills
ADM I N IST R ATI ON GU I D EL I N E S
I 17
Box 4
T he Al co ho l Use D i so rd ers Id en t i f i ca t i o n Tes t : In t erv i ew Versi o n

Read quest i ons as wri tten . Re c ord ans wers c arefu lly. Beg i n the AUDIT by sayi ng Now I am go i ng to ask you some quest i ons about your use of a l c oho li c beverages duri ng th is past year. Exp l a i n what is meant by a l c oho li c beverages by usi ng l o c a l examp l es of beer, w i ne , vodka , et c . Code ans wers i n terms of standard dri nks . Pl a c e the c orre c t ans wer number i n the box at the ri ght . 1 . How often do you have a dri nk c onta i n i ng a l c oho l? (0) (1) (2) (3) (4) Never [Sk i p to Q s 9-10] Month ly or l ess 2 to 4 t i mes a month 2 to 3 t i mes a week 4 or more t i mes a week 6 . How often duri ng the l ast year have you needed a f irst dri nk i n the morn i ng to get yourse l f go i ng after a heavy dri nk i ng sessi on? (0) (1) (2) (3) (4) Never Less than month ly Month ly Week ly Da ily or a l most da ily
2 . How many dri nks c onta i n i ng a l c oho l do you have on a typ i c a l day when you are dri nk i ng? (0) (1) (2) (3) (4) 1 or 2 3 or 4 5 or 6 7 , 8 , or 9 10 or more
7 . How often duri ng the l ast year have you had a fee li ng of gu il t or remorse after dri nk i ng? (0) (1) (2) (3) (4) Never Less than month ly Month ly Week ly Da ily or a l most da ily
3 . How often do you have six or more dri nks on one o cc asi on? (0) Never (1) Less than month ly (2) Month ly (3) Week ly (4) Da ily or a l most da ily Sk i p to Quest i ons 9 and 10 i f Tota l Sc ore for Quest i ons 2 and 3 = 0 4 . How often duri ng the l ast year have you found that you were not ab l e to stop dri nk i ng on c e you had started? (0) (1) (2) (3) (4) Never Less than month ly Month ly Week ly Da ily or a l most da ily
8 . How often duri ng the l ast year have you been unab l e to remember what happened the n i ght before be c ause you had been dri nk i ng? (0) (1) (2) (3) (4) Never Less than month ly Month ly Week ly Da ily or a l most da ily
9 . Have you or someone e lse been i n j ured as a resu l t of your dri nk i ng? (0) (2) (4) No Yes, but not i n the l ast year Yes, duri ng the l ast year
5 . How often duri ng the l ast year have you fa il ed to do what was norma lly expe c ted from you be c ause of dri nk i ng? (0) (1) (2) (3) (4) Never Less than month ly Month ly Week ly Da ily or a l most da ily
10 . Has a re l at ive or fri end or a do c tor or another hea l th worker been c on c erned about your dri nki ng or suggested you c ut down? (0) No (2) Yes, but not i n the l ast year (4) Yes, duri ng the l ast year
Re c ord tota l of spe c i f i c i tems here If tota l is greater than re c ommended c ut-off , c onsu l t Users Manua l .
18
often symptoms o cc ur. Provi de the pat i ent w i th the response c ategori es g iven for ea c h quest i on (for examp l e , Never, Severa l t i mes a month , Da ily ). When a response opt i on has been c hosen , i t is usefu l to probe duri ng the i n i t i a l quest i ons to be sure that the pat i ent has se l e c ted the most a cc urate response (for examp l e , You say you dri nk severa l t i mes a week . Is th is j ust on weekends or do you dri nk more or l ess every day? ). If responses are amb i guous or evasive , c ont i nue ask i ng for c l ari f ic at i on by repeati ng the quest i on and the response opt i ons, ask i ng the pat i ent to c hoose the best one . At t i mes ans wers are d i ff i c u l t to re c ord be c ause the pat i ent may not dri nk on a regu l ar basis. F or examp l e , i f the pat i ent was dri nk i ng exc essive ly duri ng the month before an a cc i dent , but not pri or to that t i me , then i t w ill be d i ff i c u l t to c hara c teri ze the typ i c a l dri nk i ng sought by the quest i on . In these c ases i t is best to re c ord the amount of dri nk i ng and re l ated symptoms for the heavi est dri nk i ng peri od i n the past year, mak i ng note of the fa c t that th is may be atyp i c a l or transi tory for that i nd ivi dua l . Re c ord ans wers c arefu lly, mak i ng note of any spe c i a l c irc umstan c es, add i t i ona l i nformat i on , and c li n i c a l observat i ons. Often pat i ents w ill provi de the i ntervi ewer w i th usefu l c omments about the ir dri nk i ng that c an be va l uab l e i n the i nterpretat i on of the AUDIT tota l sc ore . Adm i n isteri ng the AUDIT as a wri tten quest i onna ire or by c omputer e li m i nates many of the un c erta i nt i es of pat i ent responses by a ll ow i ng on ly spe ci f ic c ho ic es.
However, i t e li m i nates the i nformat i on obta i ned from the i ntervi ew format . Moreover, i t presumes li tera cy and ab ili ty of the pat i ent to perform the requ ired a c t i ons. It may a lso requ ire l ess t i me on the part of hea l th workers, i f pat i ents c an c omp l ete the pro c ess a l one . W i th t i me at a prem i um for both hea l th workers and pat i ents, ways of shorten i ng the screen i ng pro c ess meri t c onsi derat i on .
S h o r t e n i n g t h e Sc r ee n i n g P r o c e ss
Adm i n istered e i ther ora lly or as a quest i onna ire , the AUDIT c an usua lly be c omp l eted i n two to four m i nutes and sc ored i n a few se c onds. However, for many pat i ents i t is unne c essary to adm i n ister the c omp l ete AUDIT be c ause they dri nk i nfrequent ly, moderate ly, or absta i n ent ire ly from a lc oho l . The i ntervi ew versi on of the AUDIT (Box 4) provi des two opportun i t i es to sk i p quest i ons for su c h pat i ents. If the pat i ent ans wers i n response to Quest i on 1 that no dri nk i ng has o cc urred duri ng the l ast year, the i ntervi ewer may sk i p to Quest i ons 9-10 , responses to wh ic h may i nd ic ate past problems w ith a lc oho l. Pat ients who sc ore po ints on these questions may be c onsidered at risk i f they beg i n to dri nk aga i n , and shou l d be advised to avo i d a lc oho l . It is re c ommended that th is sk i p out i nstru c t i on on ly be used w i th the i ntervi ew or c omputer-assisted formats of the AUDIT. A se c ond opportun i ty to shorten AUDIT screen i ng o cc urs after Quest i on 3 has been ans wered . If the pat i ent sc ored 0 on Quest i ons 2 and 3 , the i ntervi ewer may sk i p to Quest i ons 9-10 be c ause the pat i ent s dri nk i ng has not exc eeded the l ow risk dri nk i ng li m i ts.
S C O R I NG AND I N T ER P RE TATI ON
I 19
Sco r i ng and In t erp re t a t i o n
he AUDIT is easy to sc ore . Ea c h of the quest i ons has a set of responses to c hoose from , and ea c h response has a sc ore rang i ng from 0 to 4 . In the i ntervi ew format (Box 4) the i ntervi ewer enters the sc ore (the number w i th i n parentheses) c orrespond i ng to the pat i ent s response i nto the box besi de ea c h quest i on . In the se l f-report quest i onna ire format (Append ix B), the number i n the c o l umn of ea c h response c he c ked by the pat i ent shou l d be entered by the sc orer i n the extreme right-hand c olumn . A ll the response sc ores shou l d then be added and re c orded i n the box l abe l ed Tota l . Tota l sc ores of 8 or more are re c ommended as i nd i c ators of hazardous and harmfu l a l c oho l use , as we ll as possi b l e a l c oho l dependen c e . (A c ut-off sc ore of 10 w ill provi de greater spe c i f i c i ty but at the expense of sensi t ivi ty.) Si n c e the effe c ts of a l c oho l vary w i th average body we i ght and d i fferen c es i n metabo lism , estab lish i ng the c ut off po i nt for a ll women and men over age 65 one po i nt l ower at a sc ore of 7 w ill i n crease sensit ivi ty for these popu l at i on groups. Se l e c t i on of the c ut-off po i nt shou l d be i nf l uen c ed by nat i ona l and c u l tura l standards and by c li n i c i an j udgment , wh i c h a lso determ i ne re c ommended maxi mum c onsumpt i on a ll owan c es. Te c hn i c a lly speak i ng , h i gher sc ores si mp ly i nd i c ate greater li ke li hood of hazardous and harmfu l dri nk i ng . However, su c h sc ores may a lso ref l e c t greater severi ty of a l c oho l prob l ems and dependen c e , as we ll as a greater need for more i ntensive treatment .
More deta il ed i nterpretat i on of a pat i ent s tota l sc ore may be obta i ned by determ i ni ng on wh i c h quest i ons po i nts were sc ored . In genera l , a sc ore of 1 or more on Quest i on 2 or Quest i on 3 i nd i c ates c onsumpt i on at a hazardous l eve l . P o i nts sc ored above 0 on quest i ons 4-6 (espec i a lly week ly or da ily symptoms) i mp ly the presen c e or i n c i p i en c e of a l c oho l dependen c e . P o i nts sc ored on quest i ons 7-10 i nd i c ate that a l c oho l-re l ated harm is a lready be i ng experi en c ed . The tota l sc ore , c onsumpt i on l eve l , si gns of dependen c e , and present harm a ll shou l d p l ay a ro l e i n determ i n i ng how to manage a pat i ent . The f i na l two quest i ons shou l d a lso be revi ewed to determ i ne whether pat i ents g ive evi den c e of a past prob l em (i . e ., yes, but not i n the past year ). Even i n the absen c e of c urrent hazardous dri nk i ng , posi t ive responses on these i tems shou l d be used to d isc uss the need for vi g il an c e by the pat i ent . In most c ases the tota l AUDIT sc ore w ill ref l e c t the pat i ent s l eve l of risk re l ated to a l c oho l . In genera l hea l th c are sett i ngs and i n c ommun i ty surveys, most pat i ents w ill sc ore under the c ut-offs and may be c onsi dered to have l ow risk of a l c oho lre l ated prob l ems. A sma ll er, but st ill si gn i f i c ant , port i on of the popu l at i on is li kely to sc ore above the c ut-offs but re c ord most of the ir po i nts on the f irst three quest i ons. A mu c h sma ll er proport i on c an be expe c ted to sc ore very h i gh , w i th po i nts re c orded on the dependen c e-re l ated quest i ons as we ll as exh i b i t i ng a l c oho l-re l ated prob l ems. A s yet there has been i nsuff i c i ent researc h to estab lish
20
pre c ise ly a c ut-off po i nt to d ist i ngu ish hazardous and harmfu l dri nkers (who wou l d benef i t from a bri ef i ntervent i on) from a l c oho l dependent dri nkers (who shou l d be referred for d i agnost i c eva l uat i on and more i ntensive treatment). Th is is an i mportant quest i on be c ause screeni ng programmes desi gned to i dent i fy c ases of a l c oho l dependen c e are li ke ly to f i nd a l arge number of hazardous and harmfu l dri nkers i f the c ut-off of 8 is used . These pat i ents need to be managed w i th l ess i ntensive i ntervent i ons. In genera l , the h i gher the tota l sc ore on the AUDIT, the greater the sensi t ivi ty i n f i ndi ng persons w i th a l c oho l dependen c e . Based on experi en c e ga i ned i n a study of treatment mat c h i ng w i th persons who had a w i de range of a l c oho l prob l em severi ty, AUDIT sc ores were c ompared w i th d i agnost i c data ref l e c t i ng l ow, med ium and h i gh degrees of a l c oho l dependen c e . It was found that AUDIT sc ores i n the range of 8-15 represented a med i um l eve l of a l c oho l prob l ems whereas sc ores of 16 and above represented a h i gh l eve l of a l c oho l prob l ems33 . On the basis of experi en c e ga i ned from the use of the AUDIT i n th is and other researc h , i t is suggested that the fo ll ow i ng i nterpretat i on be g iven to AUDIT sc ores: Sc ores between 8 and 15 are most appropri ate for si mp l e advi c e fo c used on the redu c t i on of hazardous dri nk i ng . Sc ores between 16 and 19 suggest bri ef c ounse li ng and c ont i nued mon itori ng .
AUDIT sc ores of 20 or above c l early warrant further d i agnost i c eva l uat i on for a l c oho l dependen c e . In the absen c e of better researc h these gu i de li nes shou l d be c onsi dered tentat ive , sub j e c t to c li n i c a l j udgment that takes i nto a cc ount the pat i ent s med i c a l c ond i t i on , fam ily h istory of a l c oho l probl ems and perc e ived honesty i n respondi ng to the AUDIT quest i ons. Wh il e use of the 10-quest i on AUDIT quest i onna ire w ill be suff i c i ent for the vast ma j ori ty of pat i ents, spe c i a l c irc umstan c es may requ ire a c li n i c a l screen i ng pro c edure . F or examp l e , a pat i ent may be resistant , un c ooperat ive , or unab l e to respond to the AUDIT quest i ons. If further c onf irmat i on of possi b l e dependen c e is warranted , a physi c a l exam i nat i on proc edure and l aboratory tests may be used , as descri bed i n Append ix D .
HOW TO H EL P PATI E N TS
I 21
Ho w t o Hel p Pa t i en t s
si ng the AUDIT to screen pat i ents is on ly the f irst step i n a pro c ess of he l p i ng redu c e a lc oho l-re l ated prob l ems and risks.
Box 5
Hea l th c are workers must de c i de what servi c es they c an provi de to pat i ents who sc ore posi t ive . On c e a posi t ive c ase has been i dent i f i ed , the next step is to provi de an appropri ate i ntervent i on that meets the needs of ea c h pat i ent . Typ i c a lly, a l c oho l screen i ng has been used pri marily to f i nd c ases of a l c oho l dependen c e , who are then referred to spe c i a li zed treatment . In re c ent years, however, advan c es i n screeni ng pro c edures have made i t possi b l e to screen for risk fa c tors, su c h as hazardous dri nk i ng and harmfu l a l c oho l use . Usi ng the AUDIT Total Sc ore , there is a simple way to provi de ea c h pat i ent w i th an appropriate i ntervent i on , based on the l eve l of risk . Wh il e th is d isc ussi on w ill fo c us on he l p i ng those pat i ents who sc ore posi t ive on the AUDIT, sound preventat ive pra c t i c e a lso c a lls for report i ng screen i ng resu l ts to those who sc ore negat ive . These pat i ents shou l d be rem i nded about the benef i ts of l ow risk dri nk i ng or abst i nen c e and to l d not to dri nk i n c erta i n c irc umstan c es, su c h as those ment i oned i n Box 5 . F our l eve ls of risk are shown i n Box 6 . Zone I refers to l ow risk dri nk i ng or abst inen c e . The se c ond l eve l , Zone II, c onsists of a l c oho l use i n exc ess of l ow-risk gu i deli nes5 , and is genera lly i nd i c ated when the AUDIT sc ore is between 8 and 15 . A bri ef intervention using simple advic e and patient edu c at i on materi a ls is the most appropri ate c ourse of a c t i on for these pat i ents. The
A dv i s e Pa t i en t s n o t t o D r i nk
When operat i ng a veh i c l e or ma c h i nery When pregnant or c onsi deri ng pregnan cy If a c ontra i nd i c ated med i c a l c ond i t i on is present After usi ng c erta i n med i c at i ons, su c h as sedat ives, ana l gesi cs, and se l e c ted ant i hypertensives
th ird l eve l , Zone III, is suggested by AUDIT sc ores i n the range of 16 to 19 . Harmfu l and hazardous dri nk i ng c an be managed by a c omb i nat i on of si mp l e advi c e , bri ef c ounse li ng and c ont i nued mon i tori ng , w i th further d i agnost ic eva l uat i on i nd ic ated if the patient fails to respond or is suspe c ted of possi b l e a lc oho l dependen c e . The fourth risk l eve l is suggested by AUDIT sc ores i n exc ess of 20 . These pat i ents shou l d be referred to a spe ci a list for d i agnost ic eva l uat i on and possi b l e treatment for a l c oho l dependen c e . If these servic es are not ava ilab l e , these pat i ents c an be managed i n pri mary c are , espe c i a lly when mutua l he l p organ i zat i ons are ab l e to provi de c ommun i ty-based support . Usi ng a stepped-c are approa c h , pat i ents c an be managed f irst at the l owest l eve l of i ntervent i on suggested by their AUDIT sc ore . If they do not respond to the i n i t i a l i ntervent i on , they shou l d be referred to the next l eve l of c are .
22
Box 6 R i sk Level
Zone I Zone II Zone III Zone IV
In t erven t i on
A l c oho l Edu c at i on Si mp l e Advi c e Si mp l e Advi c e p l us Bri ef Counse li ng and Cont i nued Mon i tori ng Referra l to Spe c i a list for D i agnost i c Eva l uat i on and Treatment
AU D I T sc o r e*
0-7 8-15 16-19 20-40
*The AUDIT c ut-off sc ore may vary sli ght ly depend i ng on the c ountrys dri nk i ng patterns, the a l c oho l c ontent of standard dri nks, and the nature of the screen i ng program . C li n i c a l j udgment shou l d be exerc ised i n c ases where the pat i ent s sc ore is not c onsistent w i th other evi den c e , or i f the pat i ent has a pri or h istory of a l c oho l dependen c e . It may a lso be i nstru c t ive to revi ew the pat i ent s responses to i nd ivi dua l quest i ons dea li ng w i th dependen c e symptoms (Quest i ons 4 , 5 and 6) and a l c oho l-re l ated prob l ems (Quest i ons 9 and 10). Provi de the next h i ghest l eve l of i ntervent i on to pat i ents who sc ore 2 or more on Quest i ons 4 , 5 and 6 , or 4 on Quest i ons 9 or 10 .
Bri ef i ntervent i ons for hazardous and harmfu l dri nk i ng c onst i tute a vari ety of a c t ivi t i es c hara c teri zed by the ir l ow i ntensi ty and short durat i on . They range from 5 m i nutes of si mp l e advi c e about how to redu c e hazardous dri nk i ng to severa l sessi ons of bri ef c ounse li ng to address more c omp li c ated c ond i t i ons36 . Intended to provi de early i ntervent i on , before or soon after the onset of a lc oho l-re l ated prob l ems, bri ef i ntervent i ons c onsist of feedba c k of screen i ng data desi gned to i n crease mot ivat i on to c hange dri nk i ng behavi our, as we ll as si mp l e advi c e , hea l th edu c at i on , sk ill bu il d i ng , and pra c t i c a l suggest i ons. Over the l ast 20 years pro c edures have been deve l oped that pri mary c are pra c t it i oners c an read ily l earn and pra c t i c e to address hazardous and harmfu l dri nk i ng . These pro c edures are summari zed i n Box 7 .
A number of random i zed c ontro ll ed tri a ls have evaluated the effic a cy of this approa c h , show i ng c onsistent ly posi t ive benef i ts for
Box 7
E l e m en t s o f B r i e f I n t e r v en t i o n s
Present screen i ng resu l ts Ident i fy risks and d isc uss c onsequen c es Provi de med i c a l advi c e So li c i t pat i ent c omm i tment Ident i fy goa lredu c ed dri nk i ng or abst i nen c e G ive advi c e and en c ouragement
HOW TO H EL P PATI E N TS
I 23
pat i ents who are not dependent on a lc oho l36 , 37 , 38 . A c ompan i on WHO manua l , Bri ef Intervent i on for Hazardous and Harmfu l Dri nk i ng: A Manua l for Use i n Pri mary Care , provi des more i nformat i on on th is approa c h . Referra l to a lc oho l spe ci a lty c are is c ommon among those pri mary c are pra c t i t i oners who do not have c ompeten cy i n treat i ng a l c oho l use d isorders and where spe c i a l ty c are is ava il ab l e . Consi derat i on must be g iven to the w illi ngness of pat i ents to a cc ept referra l and treatment . Many pat i ents underest i mate the risks asso c i ated w i th dri nk i ng; others may not be prepared to adm i t and address the ir dependen c e . A bri ef i ntervent i on , adapted to the purpose of i n i t i at i ng a referra l usi ng data from a c li n i c a l exam i nat i on and b l ood tests, may he l p to address pat i ent resistan c e . F o ll ow-up w i th the pat i ent and the spe c i a l ty provi der may a lso assure that the referra l is a cc epted and treatment is re c e ived . D i agnosis is a ne c essary step fo ll ow i ng h i gh posi t ive sc ori ng on the AUDIT, si n c e the i nstrument does not provi de suff ic i ent basis for estab lish i ng a management or treatment p l an . Wh il e persons asso c i ated w i th the screen i ng programme shou l d have a basi c fam ili ari ty w i th the cri teri a for a l c oho l dependen c e , a qua lif i ed professi ona l who is tra i ned i n the d i agnosis of a l c oho l use d isorders4 shou l d c ondu c t th is assessment . The best method of estab lish i ng a d i agnosis is through the use of a standard i zed , stru ctured , psyc h i atri c i ntervi ew, su c h as the
C IDI39 or the SC AN 40 . The a l c oho l se c t i ons of these i ntervi ew s requ ire 5 to 10 m i nutes to c omp l ete . The Tenth revisi on of the Internat i ona l C l assi f i c at i on of D iseases (I CD-10)4 provi des deta il ed gu i de li nes for the d i agnosis of a c ute a l c oho l i ntoxi c at i on , harmfu l use , a lc oho l dependen c e syndrome , w i thdrawa l state , and re l ated med i c a l and neuropsyc h i atri c c ond i t i ons. The I CD-10 cri teri a for the a l c oho l dependen c e syndrome are descri bed i n Box 8 . Detoxi f i c at i on may be ne c essary for some pat i ents. Spe c i a l attent i on shou l d be pa i d to pat i ents whose AUDIT responses i nd ic ate da ily c onsumpt i on of l arge amounts of a l c oho l and/or posi t ive responses to quest i ons i nd i c at ive of possi b l e dependen c e (quest i ons 4-6). Enqu iry shou l d be made as to how l ong a pat i ent has gone si n c e havi ng an a l c oho l-free day and any pri or experi en c e of w i thdrawa l symptoms. Th is i nformat i on , a physi c a l exam inat i on , and l aboratory tests (see C li n i c a l Screen i ng Pro c edures, Append ix D) may i nform a j udgment of whether to re c ommend detoxi f i c at i on . Detoxi f i c at i on shou l d be provi ded for pat i ents li ke ly to experi en c e moderate to severe w i thdrawa l not on ly to m i n i m i ze symptoms, but a lso to prevent or manage se i zures or de liri um , and to fa c ili tate a cc eptan c e of therapy to address dependen c e . Wh il e i npat i ent detoxi f i c at i on may be ne c essary i n a sma ll number of severe c ases, ambul atory or home detoxi f i c at i on c an be used su cc essfu lly w i th the ma j ori ty of l ess severe c ases.
24
Box 8
I C D - 10 C r i t e r i a f o r t he A l c o h o l De p en d en c e S y n d r o m e
Three or more of the fo ll ow i ng man i festat i ons shou l d have o cc urred together for at l east 1 month or, i f persist i ng for peri ods of l ess than 1 month , shou l d have o cc urred together repeated ly w i th i n a 12-month peri od: a strong desire or sense of c ompu lsi on to c onsume a l c oho l; i mpa ired c apa c i ty to c ontro l dri nk i ng i n terms of i ts onset , term i nat i on , or l eve ls of use , as evi den c ed by: a lc oho l be i ng often taken i n l arger amounts or over a l onger peri od than i ntended; or by a persistent desire to or unsu cc essfu l efforts to redu c e or c ontro l a l c oho l use; a physi o l og ic a l w i thdrawa l state when a lc oho l use is redu c ed or c eased , as evi den c ed by the c hara c terist ic w i thdrawa l syndrome for a lc oho l , or by use of the same (or cl osely re l ated) substan c e w i th the i ntent i on of re li evi ng or avo i d i ng w i thdrawa l symptoms; evi den c e of to l eran c e to the effe c ts of a l c oho l , su c h that there is a need for si gn i f ic ant ly i n creased amounts of a l c oho l to a c h i eve i ntoxi c at i on or the desired effe c t , or a marked ly d i m i n ished effe c t w i th c ont i nued use of the same amount of a l c oho l; preo cc upat i on w i th a l c oho l , as man i fested by i mportant a l ternat ive p l easures or i nterests be i ng g iven up or redu c ed be c ause of dri nk i ng; or a great dea l of t i me be i ng spent i n a c t ivi t i es ne c essary to obta i n , take , or re c over from the effe c ts of a l c oho l; persistent a l c oho l use desp i te c l ear evi den c e of harmfu l c onsequen c es, as evi den c ed by c ont i nued use when the i nd ivi dua l is a c tua lly aware , or may be expe c ted to be aware , of the nature and extent of harm .
(p . 57 , WHO , 1993)
Med i c a l management or treatment of a l c oho l dependen c e has been descri bed i n previ ous WHO pub li c at i ons41 . A vari ety of treatments for a l c oho l dependen c e have been deve l oped and found effe c t ive 42 . Si gn i f i c ant advan c es have been made i n pharma c otherapy, fam ily and so c i a l support therapy, re l apse prevent i on , and behavi our-ori ented sk ills tra i n i ng i ntervent i ons.
Be c ause the d i agnosis and treatment of a l c oho l dependen c e have deve l oped as a spe c i a l ty w i th i n the ma i nstream of medic a l c are , i n most c ountri es pri mary c are pra c t i t i oners are not tra i ned or experi en c ed i n i ts d i agnosis or treatment . In su c h c ases pri mary c are screen i ng programmes must estab lish proto c o ls for referri ng pat i ents suspe c ted of be i ng a lc oho l dependent who need further d i agnosis and treatment .
P R OG R AMM E I M P LE M E N TATI ON
I 25
Prog ramme Imp l emen t a t i o n
l c oho l screen i ng and appropri ate pat i ent c are have been re c ogn i zed w i de ly as essent i a l to good med i c a l pra ct i c e . Li ke many med i c a l pra c t i c es that a c h i eve su c h re c ogn i t i on , there is often a fa il ure to i mp l ement effe c t ive te c hno l og i es w i th i n organ i zed systems of hea l th c are . Imp l ementat i on requ ires spe c i a l efforts to assure c omp li an c e of i nd ivi dua l pra c t i t i oners, overc ome obsta c l es, and adapt pro c edures to spe c i a l c irc umstan c es. Researc h i nto i mp l ementat i on has begun to produ c e usefu l gu i de li nes for effe c t ive i mp l ementat i on 43 , 44 . F our ma j or e l ements have emerged as cri t i c a l to su cc ess : p l ann i ng; tra i n i ng; mon i tori ng; and feedba c k .
p l a c e . However, both po li cy and pro c edura l de c isi ons w ill be requ ired . It is genera lly he l pfu l to i nvo lve i n p l ann i ng the staff who w ill part i c i pate i n or be affe c ted by the screen i ng operat i on . P art i c i pat i on of persons w i th d iverse perspe c t ives, experi en c e , and responsi b ili t i es is most li ke ly to i dent i fy obsta c l es and create ways to remove or surmount them . In add i t i on , the i nvo lvement of staff i n p l ann i ng yi e l ds a sense of ownersh i p over the resu l t i ng i mp l ementat i on p l an . Th is is li ke ly to i n crease the c omm i tment of i nd ivi dua ls and the group to fo ll ow the p l an and make i mprovements a l ong the way that w ill assure su cc ess. A part i a l list of i mp l ementat i on issues on wh i c h p l ann i ng is he l pfu l are presented i n Box 9 . An i mp l ementat i on p l an shou l d re c e ive forma l approva l at whatever l eve l(s) requ ired before tra i n i ng beg i ns.
Pl ann i ng is ne c essary not on ly to desi gn the a l c oho l screen i ng programme but a lso to engage part i c i pants i n the ownersh i p of the programme . Every pri mary c are pra c t i c e is un i que . Ea c h has established spe c i a l pro c edures su i ted to i ts physi c a l sett i ng , so c i a l and c u l tura l environment , pat i ent popu l at i on , e c onom i cs, staff i ng stru c ture , and even i nd ivi dua l persona li t i es. Thus, adapt i ng AUDIT screen i ng to ea c h pra c t i c e si tuat i on must i nvo lve f i tt i ng i ts essent i a l e l ements i nto th is c ontext i n a way that is most li ke ly to a c h i eve susta i ned su cc ess. If screen i ng for other hea l th c ond i t i ons and risk fa c tors is a lready part of standard pra c t i c e , those pro c edures may provi de a usefu l start i ng
Tra i n i ng is essent i a l to prepari ng a hea l th c are organ i zat i on to i mp l ement i ts p l ann i ng . However, tra i n i ng w i thout a management de c isi on to i mp l ement a screeni ng programme is li ke ly to be i neffe c t ive and even c ounter-produ c t ive . A tra i n i ng pa c kage has been deve l oped 31 to support i mp l ementat i on of AUDIT screen i ng and bri ef i ntervent i on (See Append ix E). Tra i n i ng shou l d address the cri t i c a l issues of why screen i ng is i mportant , what c ond i t i ons shou l d be i dent i f i ed , how to use the AUDIT, and opt i ma l pro c edures to assure su cc ess. Effe c t ive tra i n i ng shou l d i nvo lve staff i n a deta il ed d isc ussi on of the ir fun c t i ons and responsi b ili t i es w i th i n the new programme p l an . It shou l d a lso
26
Box 9
I m p l e m en t a t i o n Que s t i o n s
Wh i c h pat i ents w ill be screened? How often w ill pat i ents be screened? How w ill screen i ng be c oord i nated w i th other a c t ivi t i es? Who w ill adm i n ister the screen? What provi der and pat i ent materi a ls w ill be used? Who w ill i nterpret resu l ts and he l p the pat i ent? How w ill med i c a l re c ords be ma i nta i ned? What fo ll ow-up a c t i ons w ill be taken? How w ill pat i ents need i ng screen i ng be i dent i f i ed? When duri ng the pat i ent s visi t w ill screen i ng be done? What w ill be the sequen c e of a c t i ons? How w ill i nstruments and materi a ls be obta i ned , stored , and managed? How w ill fo ll ow-up be sc hedu l ed?
provi de supervised pra c t i c e i n adm i n isteri ng the AUDIT i nstrument and any other pro c edures p l anned (e . g ., bri ef i ntervent i ons, referra l , et c .). In some c ountri es many peop l e , even med i c a l staff , are a cc ustomed to th i nk on ly of a l c oho l dependen c e when other issues re l ated to a l c oho l are ra ised . It is not un c ommon for hea l th workers to be li eve that peop l e w i th a l c oho l probl ems c annot be he l ped un l ess they h i t bottom and seek treatment , and that
the on ly re c ourse is tota l abst i nen c e . Some peop l e who ho l d these be li efs may f i nd a programme of screen i ng and bri ef i ntervent i on to be fru i t l ess or threateni ng . It is cri t i c a l that spe c i a l c are is taken to a ll ow su c h issues to be addressed open ly, frank ly, and w i th attent i on to the best sc i ent i f i c evi den c e . W i th sound exp l anat i on and pat i en c e , most med i c a l staff w ill e i ther understand the va l ue of screen i ng or suspend j udgment unt il experi en c e a ll ow s a determ i nat i on of i ts va l ue .
P R OG R AMM E I M P LE M E N TATI ON
I 27
Mon i tori ng is an effe c t ive way to i mprove the qua li ty of screen i ng programme i mp l ementat i on . There are vari ous ways of measuri ng the su cc ess of an a l c oho l screen i ng programme . The number of screen i ngs performed may be c ompared to the number of peop l e present i ng who shou l d have been screened under the estab lished po li cy, produ c i ng a perc entage of screen i ng su cc ess. Re c ord i ng and tota li ng the perc entage of pat i ents who screen posi t ive is a lso a usefu l measure that en c ourages staff by estab lish i ng the need for the servi c e . Determ i n i ng the perc entage of pat i ents who re c e ived the appropri ate i ntervent i on (bri ef i ntervent i on , referra l , d i agnosis, et c .) for the ir AUDIT sc ore is a further measure of programme performan c e . F i na lly, a sma ll samp l e of pat i ents who had screened posi t ive six to twe lve months before m i ght be surveyed to provi de at l east ane c dota l evi den c e of out c ome su cc ess. Re-adm i n istrat i on of the AUDIT c an serve as the basis for measuri ng quant i tat ive out c omes.
Whatever cri teri a of su cc ess are emp l oyed , frequent feedba c k to a ll part i c i pat i ng staff is essent i a l for resu l ts to c ontri bute to enhan c ed programme performan c e i n the early peri ods of i mp l ementat i on . Wri tten reports and d isc ussi on at regu l ar staff meet i ngs w ill a lso provi de o cc asi ons at wh i c h staff c an address any prob l ems that may be i nterferi ng w i th su cc ess.
28
App end i x A
R esearch Gui d eli nes f o r t he AUDIT
he AUDIT was deve l oped on the basis of an extensive six-nat i on va li dat i on tri a l 1 , 2 . Add i t i ona l researc h has been c ondu c ted to eva l uate i ts a cc ura cy and ut ili ty i n d i fferent sett i ngs, popu l at i ons, and c u l tura l groups10 . To provi de further gu i dan c e to th is pro c ess, i t is re c ommended that hea l th researc hers use the AUDIT to ans wer some of the fo ll ow i ng quest i ons:
Does AUDIT pred i c t future a l c oho l prob l ems as we ll as the pat i ent s response to bri ef i ntervent i on and more i ntensive treatment? Th is c an be eva l uated by c ondu c t i ng repeated AUDIT screen i ng on the same i nd ivi dua l . Tota l sc ores c an be c orre l ated w i th vari ous i nd i c ators of future symptomato l ogy. It wou l d be desirab l e to know, for examp l e , whether AUDIT assesses a l c oho lre l ated prob l ems a l ong a c ont i nuum of severi ty, whether severi ty sc ores i n crease progressive ly among i nd ivi dua ls who c ont i nue to dri nk heavily, and whether sc ores d i m i n ish si gn i f i c ant ly fo ll ow i ng advi c e , c ounse li ng , and other types of i ntervent i on . A screen i ng test shou l d not be c on c e ived i n iso l at i on from i ntervent i on and treatment . It must be eva l uated i n terms of i ts i mpa c t on the morb i d i ty and morta li ty of the popu l at i on at risk . Its c ontri but i on to se c ondary and pri mary prevent i on is therefore dependent on the ava il ab ili ty of effe ct ive i ntervent i on strateg i es. What is the sensi t ivi ty, spe c i f i c i ty and pred i c t ive power of the AUDIT i n d i fferent risk groups usi ng d i fferent va li dat i on criteria? In future evaluations of the AUDIT
screen i ng pro c edures, c arefu l attent i on shou l d be g iven to the a l c oho l-re l ated phenomena to be dete c ted or pred ic ted . Emphasis shou l d be g iven to the assessment of i n i t i a l risk l eve ls, harmfu l use , and a l c oho l dependen c e . The demands of methodo l og ic a lly sound va li dat i on requ ire the use of i ndependent d i agnost ic cri teri a , wh ic h themse lves have been va li dated . Two i nstruments that may be usefu l for th is purpose are the Composi te Internat i ona l D i agnost ic Intervi ew (C IDI) and the Sc hedu l es for C li n ic a l A ssessment i n Neuropsyc h i atry (SC AN)39 , 40 . Both of these i ntervi ew s provi de i ndependent veri f ic at i on of a vari ety of a lc oho l use d isorders a cc ordi ng to I CD-10 and other d i agnost ic systems. The test c ou l d be i mproved by fo c usi ng on more c arefu lly def i ned risk groups and more spe c i f ic a lc oho l-re l ated prob l ems. Spe c i f ic at i on of c ut-off po i nts is needed for target popu l at i ons whose prob l ems are to be the fo c us of screeni ng w i th AUDIT, espe c i a lly persons w i th harmfu l use and a lc oho l dependen c e . What are the pra c t i c a l barri ers to screen i ng w i th the AUDIT? Important c onstra i nts on screen i ng tests are i mposed by c ost c onsi derat i ons and by the a cc eptab ili ty of screen i ng to both hea l th professi ona ls and the i ntended target popu l at i ons. When a screen i ng test is expensive , the resu l ts of a screeni ng programme may not j ust i fy i ts c ost . Th is is a lso true when the pro c edure is t i me c onsum i ng , overly i nvasive , or otherw ise offensive to the target group . Th is type of pro c ess eva l uat i on shou l d be c ondu c ted w i th AUDIT.
A PP E ND I X A
I 29
Can the AUDIT be sc ored to produ c e separate assessments of hazardous use , harmfu l use , and a l c oho l dependen c e? If screen i ng c an be d i fferent i ated i nto these separate doma i ns, i t may prove usefu l for the purpose of eva l uat i ng d i fferent edu c at i ona l and treatment approa c hes to se c ondary prevent i on . A l ternat ive ly, the AUDIT Tota l Sc ore provi des a genera l measure of severi ty that may be usefu l for treatment mat c h i ng and stepped-c are approa c hes to c li n i c a l management (i . e ., provi d i ng the l owest l eve l of i ntervent i on that addresses the pat i ent s i mmed i ate needs). If the pat i ent does not respond , the next h i gher step is provi ded . A l though AUDIT sc ores i n the range of 8 to 19 seem appropri ate to bri ef i ntervent i ons, further researc h is needed to f i nd the opt i ma l c ut-off po i nts that are most appropri ate for si mp l e advi c e , bri ef c ounse li ng , and more i ntensive treatment . How c an the AUDIT be used i n ep i dem io l og i c a l researc h? The AUDIT may have app li c at i ons as an ep i dem i o l og i c a l too l i n surveys of hea l th c li n i cs, hea l th servi c e systems, and genera l popu l at i on samp l es. The AUDIT was deve l oped as an i nternat i ona l i nstrument but i t c ou l d a lso be used to c ompare samp l es drawn from d i fferent nat i ona l and c u l tura l groups, w i th respe c t to the nature and preva l en c e of hazardous dri nk i ng , harmfu l dri nk i ng , and a l c oho l dependen c e . Before th is is done i t wou l d be usefu l to deve l op norms for vari ous risk l eve ls so that i nd ivi dua l and group sc ores
c an be c ompared to the d istri but i on of sc ores w i th i n the genera l popu l at i on . What is the c on c urrent va li d i ty of the AUDIT i tems and tota l sc ores when c ompared w i th d i fferent ob j e c t ive i nd i c ators of a l c oho l-re l ated prob l ems, su c h as b l ood a l c oho l l eve l , b i o c hem i c a l markers of heavy dri nk i ng , pub li c re c ords of a l c oho l-re l ated prob l ems, and observat i ona l data obta i ned from persons know l edgeab l e about the pat i ent's dri nk i ng behavi our. To the extent that verba l report pro c edures may have i ntri nsi c li m i tat i ons, i t wou l d be usefu l to eva l uate under what c irc umstan c es AUDIT resu l ts are b i ased or otherw ise i nva li d . Pro c edures to i n crease the a cc ura cy of AUDIT shou l d a lso be i nvest i gated . How a cc eptab l e is the AUDIT to pri mary c are workers? How c an screen i ng pro c edures best be taught i n the c ontext of edu c at i ng hea l th professi ona ls? How extensive ly are screen i ng pro c edures usi ng AUDIT app li ed on c e students or hea l th workers are tra i ned?
30
App end i x B
Sugg es t ed Fo rma t f o r AUDIT Sel f-R epo rt Ques t i o nnai re
n some sett i ngs there may be advantages to adm i n isteri ng the AUDIT as a quest i onna ire c omp l eted by the pat i ent rather than as an ora l i ntervi ew. Su c h an approa c h often saves t i me , c osts l ess, and may produ c e more a cc urate ans wers by the pat i ent . These advantages may a lso resu l t from adm i n istrat i on vi a c omputer. The AUDIT quest i onna ire format presented i n Box 10 may be usefu l for su c h purposes. Use of the sk i p outs provi ded i n the ora l i ntervi ew (Box 4 on page 17) is li ke ly to be too d i ff i c u l t for pat i ents to fo ll ow i n a paper adm i n istrat i on . However, they are easily a c h i eved automat i c a lly i n c omputeri zed app li c at i ons. Adm i n istrators are en c ouraged to add ill ustrat i ons of l o c a l , c ommon ly ava il ab l e beverages i n standard dri nk amounts. Quest i on 3 may requ ire mod i f i c at i on (to 4 or 5 dri nks), depend i ng on the number of standard dri nks requ ired to tota l 60 grams of pure ethano l (See Append ix C). Sc ori ng i nstru c t i ons: Ea c h response is sc ored usi ng the numbers at the top of ea c h response c o l umn . Wri te the appropri ate number asso ci ated w i th ea c h ans wer i n the c o l umn at the ri ght . Then add a ll numbers i n that c o l umn to obta i n the Tota l Sc ore . Spa c e at the bottom of the form may be desi gnated F or Off i c e Use On ly to c onta i n i nstru c t i ons or p l a c es to do c ument a c t i ons taken by hea l th workers who adm i n ister the AUDIT or provi de bri ef
i ntervent i ons. Su c h materi a l , however, shou l d be suff i c i ent ly c oded so as not to c omprom ise pat i ents' honesty i n ans weri ng AUDIT quest i ons.
A PP E ND I X B
I 31
B o x 10
The Alcohol Use Disorders Identification Test: Self-Report Version

PATIENT: Be c ause a lc oho l use c an affe c t your hea l th and c an i nterfere w i th c erta i n med ic at i ons and treatments, i t is i mportant that we ask some quest i ons about your use of a l c oho l . Your ans wers w ill rema i n c onf i dent i a l so p l ease be honest . Pl a c e an X i n one box that best descri bes your ans wer to ea c h quest i on . Quest i ons 1 . How often do you have a dri nk c onta i n i ng a l c oho l ? 0 Never 1 Month ly or l ess 3 or 4 2 2-4 t i mes a month 5 or 6 3 2-3 t i mes a week 7 to 9 4 4 or more t i mes a week 10 or more
2 . How many dri nks c onta i n i ng 1 or 2 a l c oho l do you have on a typ i c a l day when you are dri nk i ng ? 3 . How often do you have six or more dri nks on one o cc asi on ? 4 . How often duri ng the l ast year have you found that you were not ab l e to stop dri nk i ng on c e you had started ? 5 . How often duri ng the l ast year have you fa il ed to do what was norma lly expe c ted of you be c ause of dri nk i ng ? 6 . How often duri ng the l ast year have you needed a f irst dri nk i n the morn i ng to get yourse l f go i ng after a heavy dri nk i ng sessi on ? 7 . How often during the last year have you had a fee li ng of gu il t or remorse after dri nk i ng ? Never
Less than month ly Less than month ly
Month ly
Week ly
Da ily or a l most da ily Da ily or a l most da ily Da ily or a l most da ily Da ily or a l most da ily
Never
Month ly
Week ly
Never
Less than month ly
Month ly
Week ly
Never
Less than month ly
Month ly
Week ly
Never
Less than month ly Less than month ly
Month ly
Week ly
Da ily or a l most da ily Da ily or a l most da ily Yes, duri ng the l ast year Yes, duri ng the l ast year Total
8 . How often duri ng the l ast year Never have you been unab l e to remember what happened the n i ght before be c ause of your drinking? 9 . Have you or someone e lse been i n j ured be c ause of your dri nk i n g ? 10 . Has a re l at ive , fri end , do c tor, or other hea l th c are worker been c on c erned about your dri nk i ng or suggested you c ut down ? No
Month ly
Week ly
Yes, but not i n the l ast year Yes, but not i n the l ast year
No
32
App end i x C
Transl a t i o n and Ad ap t a t i o n t o Sp ec i f i c Lang uag es, Cul t ures and S t and ard s
n some c u l tura l sett i ngs and li ngu ist i c I groups, the AUDIT quest i ons c annot be transl ated li tera lly. There are a number of so c i o c u l tura l fa c tors that need to be taken i nto a cc ount i n add i t i on to semant i c mean i ng . F or examp l e , the dri nk i ng c ustoms and beverage preferen c es of c erta i n c ountri es may requ ire adaptat i on of quest i ons to c onform to l o c a l c ond i t i ons. W i th regard to transl at i on i nto other l anguages, i t shou l d be noted that the AUDIT questions have been translated into Spanish , Slavic , Norwegian , Fren c h , German , Russian , Japanese , Swah ili , and severa l other l anguages. These transl at i ons are ava il ab l e by wri t i ng to the Department of Menta l Hea l th and Substan c e Dependen c e , Worl d Hea l th Organ i zat i on , 1211 Geneva 27 , Sw i tzerl and . Before attempt i ng to transl ate AUDIT i nto other l anguages, i nterested i nd ivi dua ls shou l d c onsu l t w i th WHO Headquarters about the pro c edures to be fo ll owed and the ava il ab ili ty of other transl at i ons. for these quest i ons i n order to f i t the most c ommon dri nk si zes and a l c oho l strength i n your c ountry. The re c ommended l ow-risk dri nk i ng l eve l set i n the bri ef i ntervent i on manua l and used i n the WHO study on bri ef i ntervent i ons is no more than 20 grams of a l c oho l per day, 5 days a week (re c ommend i ng 2 non-dri nk i ng days).
H o w to C a l c u l a t e t h e C o n t e n t of A l c o h o l i n a D r i n k
The a lc oho l c ontent of a dri nk depends on the strength of the beverage and the vo lume of the c onta i ner. There are w i de vari at i ons i n the strengths of a l c oho li c beverages and the dri nk si zes c ommon ly used i n d i fferent c ountri es. A WHO survey45 i nd ic ated that beer c onta i ned between 2 % and 5% vo l ume by vo l ume of pure a lc oho l , w i nes c onta i ned 10 . 5 % to 18 . 9 % , sp iri ts vari ed from 24 . 3% to 90% , and ci der from 1 . 1 % to 17 % . Therefore , i t is essent i a l to adapt dri nk i ng si zes to what is most c ommon at the l o c a l l eve l and to know rough ly how mu c h pure a l c oho l the person c onsumes per o cc asi on and on average . Another c onsi derat i on i n measuri ng the amount of a l c oho l c onta i ned i n a standard dri nk is the c onversi on fa c tor of ethano l . That a ll ow s you to c onvert any vo l ume of a l c oho l i nto grammes. F or ea c h milliliter of ethanol, there are 0 . 79 grammes of pure ethano l . F or examp l e , 1 c an beer (330 ml) at 5% x (strength) 0 . 79 (c onversion fa c tor) = 13 grammes of ethanol 1 g l ass w i ne (140 m l) at 12 % x 0 . 79 = 13 . 3 grammes of ethano l 1 shot sp iri ts (40 m l) at 40 % x 0 . 79 = 12 . 6 grammes of ethano l .
Wh a t i s a S t a n d a r d D r i n k ?
In d i fferent c ountri es, hea l th edu c ators and researc hers emp l oy d i fferent def i n it i ons of a standard un i t or dri nk be c ause of d i fferen c es i n the typ i c a l servi ng si zes i n that c ountry. F or examp l e , 1 standard dri nk i n Canada: 13 . 6 g of pure a l c oho l 1 s dri nk i n the UK: 8 g 1 s drink in the USA: 14 g 1 s dri nk i n Austra li a or New Zea l and: 10 g 1 s dri nk i n Japan: 19 . 75 g In the AUDIT, Quest i ons 2 and 3 assume that a standard drink equivalent is 10 grams of a l c oho l . You may need to ad j ust the number of drinks in the response c ategories
A PP E ND I X D
I 33
App end i x D
Cli ni cal Screeni ng Pro ced ures
c li n i c a l exam i nat i on and l aboratory tests c an somet i mes be he l pfu l i n the dete c t i on of c hron i c harmfu l a l c oho l use . C li n i c a l screen i ng pro c edures have been deve l oped for th is purpose 34 . These i n c l ude tremor of the hands, the appearan c e of b l ood vesse ls i n the fa c e , and c hanges observed i n the mu c ous membranes (e . g ., c on j un c t ivi t is) and ora l c avi ty (e . g ., g l ossi t is), and e l evated liver enzymes. On ly qua li f i ed hea l th workers shou l d c ondu c t the exam i nat i on . Severa l of the i tems requ ire exp l anat i on i n order to make a re li ab l e d i agnosis. Con j un c t iva l i n j e c t i on . The c ond i t i on of the c on j un c t iva l t issue is eva l uated on the basis of the extent of c ap ill ary engorgement and sc l era l j aund i c e . Exam i nat i on is best c ondu c ted i n c l ear dayli ght by ask i ng the pat i ent to d ire c t h is gaze upward and then downward wh il e pu lli ng ba c k the upper and l ower eye-li ds. Under norma l c ond i t i ons, the norma l pearly wh i teness is w i de ly d istri buted . In c ontrast , c ap ill ary engorgement is ref l e c ted i n the appearan c e of burgundy-c o l oured vasc u l ar e l ements and the appearan c e of a green ish-ye ll ow t i nge to the sc l era . Abnorma l sk i n vasc u l ari zat i on . Th is is best eva l uated by exam i nat i on of the fa c e and ne c k . These areas often g ive evi den c e of f i ne w iry arteri o l es that appear as a redd ish b l ush . Other si gns of c hron i c a l c oho l i ngest i on i n c l ude the appearan c e of 'goose-f l esh " on the ne c k and ye ll ow ish b l ot c hes on the sk i n .
Hand tremor. Th is shou l d be est i mated w i th the arms extended anteri orly, ha l f bent at the e l bow s, w i th the hands rotated toward the m i d li ne . Tongue tremor. Th is shou l d be eva l uated w i th the tongue protrud i ng a short d istan c e beyond the li ps, but not too exc essive ly. Hepatomega ly. Hepat i c c hanges shou l d be eva l uated both i n terms of vo l ume and c onsisten cy. In creased vo l ume c an be gaged i n terms of f i nger breadths be l ow the c osta l marg i n . Consisten cy c an be rated as norma l , f irm , hard , or very hard . Severa l l aboratory tests are usefu l i n the dete c t i on of a l c oho l m isuse . Serum gamma-g l utamyl transferase (G GT), c arbohydrate def i c i ent transferri n (CDT), mean c orpusc u l ar vo l ume (M CV) of red b l ood c e lls and serum aspartate am i no transferase (AST) are li ke ly to provi de , at re l at ive ly l ow c ost , a possi b l e i nd i c at i on of re c ent exc essive a l c oho l c onsumpt i on . It shou l d be noted that fa lse posi t ives c an o cc ur when the i nd ivi dua l uses drugs (su c h as barb i turates) that i ndu c e G GT, or has hand tremor be c ause of nervousness, neuro l og i c a l d isorder, or n i c ot i ne dependen c e .
34
App end i x E
Trai ni ng Ma t er i al s f o r AUDIT
ra i n i ng materi a ls and other resourc es have been deve l oped to tea c h AUDIT screen i ng and bri ef i ntervent i on te c hn i ques. These i n c l ude vi deos, i nstru c tor's manua ls, and l eaf l ets.
Resourc es that c an be used to obta i n tra i n i ng to use the AUDIT to screen for a l c oho l prob l ems are listed be l ow: Anderson , P. A l c oho l and pri mary hea l th c are . Worl d Hea l th Organ i zat i on , Reg i ona l Pub lic at i ons, European Seri es no . 64 , 1996 . Pro j e c t NEADA (Nursi ng Edu c at i on i n A l c oho l and Drug Abuse), c onsists of a 30 m i nute vi deo ent i t l ed A l c oho l Screen i ng and Bri ef Intervent i on and an Instru c tor's Manua l 31 w i th l e c ture materi a l , ro l e p l ayi ng exerc ises, gu i de li nes for group d isc ussi ons, and l earner a c t ivi ty assi gnments. Ava il ab l e through the U .S. Nat i ona l C l eari nghouse on A l c oho l and Drug Informat i on : w w w. hea l th . org or c a ll 1-800-729-6686 . A l c oho l risk assessment and i ntervent i on (ARA I) pa c kage . Ontari o , Co ll ege of F am ily P hysi c i ans of Canada , 1994 . Su llivan , E., and F l em i ng , M . A Gu i de to Substan c e Abuse Servi c es for Pri mary Care C li n i c i ans, Treatment Improvement Proto c o l Seri es, 24 , U .S. Department of Hea l th and Human Servi c es, Ro c kvill e , MD 20857 , 1997 .
RE F ERE N C E S
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R e f erences
1 . Saunders, J.B., Aasl and , O . G ., Babor, T. F., de l a F uente , J.R. and Grant , M . Deve l opment of the A l c oho l Use D isorders Ident i f i c at i on Test (AUDIT): WHO c o ll aborat ive pro j e c t on early dete c t i on of persons w i th harmfu l a lc oho l c onsumpt i on . II. Add ic t i on , 88 , 791-804 , 1993 . 2 . Saunders, J.B., Aasl and , O . G ., Amundsen , A . and Grant , M . A l c oho l c onsumpt i on and re l ated prob l ems among pri mary hea l th c are pat i ents: WHO Co ll aborat ive Pro j e c t on Early Dete c t i on of P ersons w i th Harmfu l A l c oho l Consumpt i on I. Add i c t i on , 88 , 349-362 , 1993 . 3 . Babor, T., Campbe ll , R., Room , R. and Saunders, J.(Eds.) Lexi c on of A l c oho l and Drug Terms, Worl d Hea l th Organ i zat i on , Geneva , 1994 . 4 . Worl d Hea l th Organ i zat i on . The ICD10 C l assi f i c at i on of Menta l and Behavi oura l D isorders: D i agnost i c criteri a for researc h , Worl d Hea l th Organ i zat i on , Geneva , 1993 . 5 . Anderson , P., Cremona , A ., P aton , A ., Turner, C . & Wa lla c e , P. The risk of a lc oho l. Add ic tion 88 , 1493-1508 , 1993 . 6 . Edwards, G ., Anderson , P., Babor, T. F., Cass we ll , S., F erren c e , R., Ge isbre c ht , N ., Godfrey, C ., Ho l der, H ., Lemmens, P., Make l a , K ., M i dan i k , L., Norstrom , T., O sterberg , E., Rome lsj o , A ., Room , R., Si mpura , J., Skog ., O . A l c oho l
P o li cy and the P ub li c Good . Oxford Un iversi ty Press, 1994 .

7 . Worl d Hea l th Organ i zat i on . Prob l ems re l ated to a l c oho l c onsumpt i on , Report of a WHO Expert Comm i ttee . Te c h . Report Seri es 650 , Geneva , WHO , 1980 . 8 . Kre i tman , N . A l c oho l c onsumpt i on and the prevent i on paradox. Bri t ish Journa l of Add i c t i on 81 , 353-363 , 1986 9 . Murray, R. M . Screen i ng and early dete c t i on i nstruments for d isab ili t i es re l ated to a l c oho l c onsumpt i on . In: Edwards, G ., Gross, M . M ., Ke ll er, M ., Moser, J. & Room , R. (Eds) A l c oho lRe l ated D isab ili t i es. WHO Offset P ub . No . 32 . Geneva , Worl d Hea l th Organ i zat i on , 89-105 , 1977 . 10 . A ll en , J.P., Li tten , R.Z., F ert i g , J.B. and Babor, T. A revi ew of researc h on the A l c oho l Use D isorders Ident i f i c at i on Test (AUDIT). A l c oho lism: C li n i c a l and Experi menta l Researc h 21(4): 613619 , 1997 . 11 . Cherp i te l , C .J. Ana lysis of c ut po i nts for screen i ng i nstruments for a l c oho l prob l ems i n the emergen cy room . Journa l of Stud i es on A l c oho l 56:695-700 , 1995 . 12 . Con i grave , K . M ., Ha ll , W. D ., Saunders, J.B., The AUDIT quest i onna ire: c hoosi ng a c ut-off sc ore . Add i c t i on 90:1349-1356 , 1995 .
36
13 . Vo l k , R.J., Ste i nbauer, J.R., Cantor, S.B. and Ho l zer, C .E. The A l c oho l Use D isorders Identific ation Test (AUDIT) as a screen for at-risk dri nk i ng i n pri mary c are pat i ents of d i fferent ra c i a l/ethn i c ba c kgrounds. Add i c t i on 92(2):197206 , 1997 . 14 . Ri gma i den , R.S., Pistore ll o , J., Johnson , J., Mar, D . and Vea c h , T.L. Add ic t i on med ici ne i n ambu l atory c are: Preva l en c e patterns i n i nterna l med ici ne . Substan c e Abuse 16:49-57 , 1995 . 15 . Pi cc i ne lli , M ., Tessari , E., Borto l omasi , M ., Piasere , O ., Semenzin , M . Garzotto , N . and Tanse ll a , M . Eff i c a cy of the a l c oho l use d isorders i dent i f i c at i on test as a screen i ng too l for hazardous a l c oho l i ntake and re l ated d isorders i n pri mary c are: a va li d i ty study. Bri t ish Med ic a l Journa l 314(8) 420-424 , 1997 . 16 . Sk i psey, K ., Burl eson , J. A . and Kranz l er, H .R. Ut ili ty of the AUDIT for the i dent i f i c at i on of hazardous or harmfu l dri nk i ng i n drug-dependent pat i ents. Drug and A l c oho l Dependen c e 45:157-163 , 1997 . 17 . C l aussen , B. and Aasl and , O . G . The A lc oho l Use Disorders Identific ation Test (AUDIT) i n a rout i ne hea l th exami nat i on of l ong-term unemp l oyed . Add i c t i on 88:363-368 , 1993 . 18 . Fl em i ng , M . F., Barry, K .L. and Ma c Dona l d , R. The a lc oho l use d isorders i dent i f ic at i on test (AUDIT) i n a c o ll ege samp l e . Internat i ona l Journa l of the Add ic t i ons 26:1173-1185 , 1991 .
19 . P owe ll , J.E. and M cInness, E. A l c oho l use among o l der hosp i ta l pat i ents: F i nd i ngs from an Austra li an study. Drug and A l c oho l Revi ew 13:5-12 , 1994 . 20 . Isaa cson , J. H ., But l er, R., Za c harek , M . and Tze l ep is, A . Screen i ng w i th the A l c oho l Use D isorders Ident i f i c at i on Test (AUDIT) i n an i nner-c i ty popu l at i on . Journa l of Genera l Interna l Med i c i ne 9:550-553 , 1994 . 21 . F i e lli n , D . A ., Carri ngton , R. M . and O Connor, P. G . Screen i ng for a l c oho l prob l ems i n pri mary c are: a systemati c revi ew. Arc h ives of Interna l Med i c i ne 160: 1977-1989 , 2000 . 22 . Ivis, F.J., Ad l af , E. M . and Rehm , J. In c orporat i ng the AUDIT i nto a genera l popu l at i on te l ephone survey: a methodo l og i c a l experi ment . Drug & A l c oho l Dependen c e 60:97-104 , 2000 . 23 . Lapham , S. C ., Sk i pper, B.J., Brown , P., Chadbun c ha c hai, W., Suriyawongpaisal, P. and P a isarnsil p , S. Preva l en c e of a l c oho l use d isorders among emergen cy room pat i ents i n Tha il and . Add i c t i on 93(8), 1231-1239 , 1998 . 24 . Ste i nbauer, J.R., Cantor, S.B., Ho l der, C .E. and Vo l k , R.J. Ethn i c and sex b i as i n pri mary c are screen i ng tests for a l c oho l use d isorders. Anna ls of Interna l Med i c i ne 129: 353-362 , 1998 .
RE F ERE N C E S
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25 . C l ements, R. A cri t i c a l eva l uat i on of severa l a l c oho l screen i ng i nstruments usi ng the C IDI-SA M as a cri teri on measure . A l c oho lism: C li n i c a l and Experi menta l Researc h 22(5):985993 , 1998 . 26 . Hays, R. D ., Merz , J. F. and N i c ho l as, R. Response burden , re li ab ili ty, and va li d i ty of the C A GE, Short M AST, and AUDIT a l c oho l screen i ng measures. Behavi ora l Researc h Methods, Instruments & Computers 27:277280 , 1995 . 27 . Bohn , M .J., Babor, T. F. and Kranz l er, H .R. The A l c oho l Use D isorders Ident i f i c at i on Test (AUDIT): Va li dat i on of a screen i ng i nstrument for use i n med i c a l sett i ngs. Journa l of Stud i es on A l c oho l 56:423-432 , 1995 . 28 . Con i grave , K . M ., Saunders, J.B. and Rezn i k , R.B. Pred i c t ive c apa c i ty of the AUDIT quest i onna ire for a lc oho l-re l ated harm . Add i c t i on 90:1479-1485 , 1995 . 29 . Si n c l a ir, M ., M cRee , B. and Babor, T. F. Eva l uat i on of the Re li ab ili ty of AUDIT. Un iversi ty of Conne c t i c ut Sc hoo l of Med i c i ne , A l c oho l Researc h Center, (unpub lished report), 1992 . 30 . Babor, T. F., de l a F uente , J.R., Saunders, J. and Grant , M . AUDIT The A l c oho l Use D isorders Ident i f i c at i on Test: Gu i de li nes for Use i n Pri mary Hea l th Care . WHO / MNH/DAT 89 . 4 , Worl d Hea l th Organ i zat i on , Geneva , 1989 .
31 . M cRee , B., Babor, T. F. and Churc h , O . M . Instru c tor's Manua l for A l c oho l Screen i ng and Bri ef Intervent i on . Pro j e c t NEADA , Un iversi ty of Conne c t i c ut Sc hoo l of Nursi ng , 1991 . 32 . Gomel, M . and Wutzke , S. Phase III World Hea l th Organ i zat i on Co ll aborat ive Study. Pro c edures Manua l Strand III, P art 1 . Dept . of Psyc h i atry, Un iversi ty of Sydney, New South Wa l es, 1995 . 33 . M ill er, W.R., Zweben , A ., D i C l emente , C . C . and Ryc htari k , R. G . Mot ivat i ona l enhan c ement therapy manua l: A c li n i c a l researc h gu i de for therap ists treat i ng i nd ivi dua ls w i th a l c oho l abuse and dependen c e . Pro j e c t M ATCH Monograph Seri es, Vo l . 2 . Ro c kvill e MD: NI A A A , 1992 . 34 . Babor, T. F., We ill , J., Treffard i er, M . and Benard , J. Y. Dete c t i on and d i agnosis of a l c oho l dependen c e usi ng the Le Go gri d method . In: Chang N (Ed .) Early i dent i f i c at i on of a l c oho l abuse . NI A A A Researc h Monograph 17 , DHHS P ub . No . (ADM) 85-1258 , Wash i ngton , D . C . USG P O , 1985; 321-338 . 35 . Saunders, J.B. and Aasl and , O . G . WHO Co ll aborat ive Pro j e c t on Ident i f i c at i on and Treatment of P ersons w i th Harmfu l A l c oho l Consumpt i on . Geneva , Sw i tzerl and , Worl d Hea l th Organ i zat i on (Unpub lished Do c ument WHO / MNH/DAT/86 . 3), 1987 .
38
36 . Bi en , T. H ., M ill er, W.R. and Ton i gan , S. Bri ef i ntervent i on for a lc oho l probl ems: a revi ew. Add ic t i on 88:315-336 , 1993 . 37 . Kahan , M ., W ilson , L. and Be c ker, L. Effe c t iveness of physi c i an-based i ntervent i ons w i th prob l em dri nkers: A revi ew. Canad i an Med i c a l A sso c i at i on Journa l , 152(6):851-859 , 1995 . 38 . W il k , A .I., Jensen , N . M . and Havi ghurst , T. C . Meta-ana lysis of random i zed c ontro l tri a ls addressi ng bri ef i ntervent i ons i n heavy a l c oho l dri nkers. Journa l of Genera l Interna l Med i c i ne , 12:274-283 , 1997 . 39 . Rob i ns, L. N ., W i ng , J., W i tt c hen , H . U ., He l zer, J.E., Babor, T. F., Burke , J., F armer, A ., Jab l ensk i , A ., Pi c kens, R, Reg i er, D ., Sartori us, N . and Tow l e , L. The Composi te Internat i ona l D i agnost i c Intervi ew: An ep i dem i ol og i c a l i nstrument su i tab l e for use i n c on j un c t i on w i th d i fferent d i agnost i c systems and i n d i fferent c u l tures. Arc h ives of Genera l Psyc h i atry, 45:1069-1077 , 1988 . 40 . W i ng , J. K ., Babor, T., Brugha , T., Burke , J., Cooper, J.E., G i e l , R., Jab l ensk i , A ., Reg i er, D . and Sartori us, N . SC AN - Sc hedu l es for C li n ic a l A ssessment i n Neuropsyc h i atry. Arc h ives of Genera l Psyc h i atry 47:589-593 , 1990 .
41 . Heather, N . Treatment approa c hes to a l c oho l prob l ems. Copenhagen , WHO Reg i ona l Off i c e for Europe , 1995 (WHO Reg i ona l P ub li c at i ons, European Seri es, No . 65). 42 . Nat i ona l Inst i tute on A l c oho l Abuse and A l c oho lism . 10th Spe c i a l Report to the U .S. Congress on A l c oho l and Hea l th . Ro c kvill e , MD , 2000 . 43 . Ric hmond , R.L. and Anderson , P. Researc h i n genera l pra c t i c e for smokers and exc essive dri nkers i n Austra li a and the UK . III. D issem i nat i on of i ntervent i ons. Add i c t i on 89 , 49-62 , 1994 . 44 . Babor, T. F. and H i gg i ns-Bi dd l e , J. C . A l c oho l screen i ng and bri ef i ntervent i on: d issem i nat i on strateg i es for med i c a l pra c t i c e and pub li c hea l th . Add i c t i on 95(5):677-686 , 2000 . 45 . F i nn ish F oundat i on for A l c oho l Stud i es. Internat i ona l Stat ist i cs on A l c oho li c Beverages : Produ c t i on , Trade and Consumpt i on 1950-1972 . He lsi nk i , F i nn ish F oundat i on for A l c oho l Stud i es, 1977 .
NOT E S
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N o t es
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WHO/MSD/MSB/01.

6a Origina l: English Distribut ion: Genera l

Thomas F. Babor John C. Higgins-Biddle John B. Saunders Maristela G. Monteiro

The Alcohol Use Disorders Ident i f ic at ion Test

W or l d Hea l t h Organ i zat i on Department o f M ental Health and S ub s tan c e Dependen c e

WHO/MSD/MSB/01.6a Origina l: English Distribut ion: Genera l

Thomas F. Babor John C. Higgins-Biddle John B. Saunders Maristela G. Monteiro

The Alcohol Use Disorders Ident i f ic at ion Test

W or l d Hea l t h Organ i zat i on Department o f M ental Health and S ub s tan c e Dependen c e

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

Premature ag i ng . Dri nker's nose .

Tremb li ng hands. T i ng li ng f i ngers. Numbness. P a i nfu l nerves. U l c er.

Inf l ammat i on of the pan creas.

Impa ired sensat i on l ead i ng to fa lls.

Numb , t i ng li ng toes. P a i nfu l nerves.

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

P hysi c i an s Room Surgery Genera l Hosp i ta l wards Out-pat i ent c li n i c

Psyc h i atri c hosp i ta l

Psyc h i atrist , staff

Court , j a il , prison Other hea l th-re l ated fa c ili t i es

Off i c ers, Counse ll ors Hea l th and human servi c e workers

M ili tary Servi c es Work p l a c e Emp l oyee assistan c e Programme

Med i cs Emp l oyee assistan c e staff

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

Dev el op men t and Vali d a t i o n o f t he AUDIT

D E V EL O P M E N T AND VA L I DATI ON O F T H E AUD IT

Harmfu l A l c oho l Use

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

D E V EL O P M E N T AND VA L I DATI ON O F T H E AUD IT

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

Ad m i ni s tra t i o n Gui d eli nes

ADM I N IST R ATI ON GU I D EL I N E S

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

ADM I N IST R ATI ON GU I D EL I N E S

T he Al co ho l Use D i so rd ers Id en t i f i ca t i o n Tes t : In t erv i ew Versi o n

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

Sco r i ng and In t erp re t a t i o n

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

Prog ramme Imp l emen t a t i o n

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

The Alcohol Use Disorders Identification Test: Self-Report Version

Less than month ly Less than month ly

Less than month ly

Less than month ly

Less than month ly Less than month ly

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

P o li cy and the P ub li c Good . Oxford Un iversi ty Press, 1994 .

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

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