Screening and Assessment

Graphic of 4 step screening and assessment process

Step 1: Ask: quantity and frequency, binge, CAGE, and AUDIT

Step 2: Assess: Academic, Social, Behavioral, and Medical

Step 3: Advise Appropriate Action: Iterative process of Brief Intervention, Motivational Interview, and Referral

Step 3: Follow-Up Supportive Care: Iterative process of Brief Intervention, Motivational Interview, and Referral

Screening - What We know...

1. Quantity, frequency, and binge drinking questions seem to have the best psychometric properties to detect high-risk college drinking.
2. Asking about alcohol use in the context of other behaviors such as smoking, exercise, nutrition, and sexual activities results in more accurate alcohol use information.
3. Just asking the question may change alcohol use and norms.
4. Context! Method of administration! Skills of the provider! All are critical factors!
5. No current biological or laboratory markers are sufficiently sensitive for routine screening in college students.
6. Denial is much less common than previously thought! From a public health perspective, it is unimportant; part of the noise.

College Students

Clinical Opportunities: Screening...

• Health maintenance visits
• School and sports physicals
• Foreign travel consultation
• Possible alcohol-related symptoms
• Headaches
• Depression
• Anxiety
• Acute care visits for trauma

Approach

• Be sincere
• Be respectful
• Emphasize confidentiality
• Establish trust

Alcohol Screening: Consumption Questions To Detect At-Risk and Problem Drinkers

Frequency: “On average, how many days per week do you drink alcohol?”

Quantity: “On a typical day when you drink, how many drinks do you have?”

Binge drinking: “How many times did you have more than four drinks on a single occasion in the last 30 days?”

Alcohol Screening: To Detect At-Risk or Problem Drinkers

Single questions developed by Cherpital, Vinson, Brown and others.

• “Do you have five or more drinks one or more times per week?”
• “Have you felt the need to cut down on your alcohol use?”
• “How many drinks does it take to get high?”
• “How many six packs did you drink last weekend?”

Alcohol Screening: To Detect Dependent Drinkers - CAGE

• “Have you ever felt that you should Cut down on your drinking?”
• “Have people Annoyed you by criticizing your drinking?"
• “Have you ever felt bad or Guilty about your drinking?"
• “Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?” (Eye opener)

Additional Screening Questions: RAFFT (Cherpital)

• Relax - Use to relax?
• Alone - Use alone?
• Family - Use with family?
• Friends - Use with friends?
• Trouble - Had any problems related to alcohol use?

Additional Screening Questions Used to Predict Risk

Family history

• Has anyone in your family, such as as your parents or siblings, had any problems with alcohol?
• Do you think they drink too much?
• Did their drinking affect you when you were growing up?

Additional Screening Questions Used to Predict Risk

• Age at first drink?
• Age first time you became drunk?
• How many times did you drink in high school?
• How many times a week did you drink alcohol in high school?

Self Administered Pencil and Paper Questionnaire

Alcohol Use Disorder Inventory Test (AUDIT) (10 questions)

• 3 quantity/frequency questions
• 3 CAGE questions
• 4 consequence (blackouts, injuries, DUI, physician advice)

Alcohol use Disorders Identification Test (AUDIT)

**A score of 8 or more is suggestive of at-risk drinking. Patients who score positive on the AUDIT should be assessed for potential alcohol-related problems.

AUDIT Reference: Babor TF, de la Fuente JR, Saunders J, Grant M. AUDIT: The Alcohol use Disorders Identification Tests: Guidelines for use in Primary health Care. Geneva, Switzerland: World Health Organization, 1992.

Biological Measures

• Blood Alcohol Level/Breathalyzer
• MCV (Mean Corpuscular Volume)
• GGT (Gamma-Glutamyl Transferase)
• CDT (Carbohydrate-Deficient Transferrin)
• Urine Toxicology Screens

A “Standard Drink”

• A mug of ordinary beer, ale, or malt liquor 12 oz.
• A single shot of spirits -- whisky, gin, vodka, etc. 1.5 oz.
• A glass of wine 5 oz.
• A wine cooler 12 oz.
• A small glass of sherry, liqueur, or aperitif 4 oz.

Biological Measures

Blood Alcohol Level (BAL) 0.015 mg% = 1 drink (14 grams in US)

• a standard drink is metabolized in 60-90 minutes in an average person
• 3-4 standard drinks over 1-2 hours to get to 0.08 mg% (women)
• 5-6 standard drinks to get to 0.08 mg% (men)

Assessment

• Assess for alcohol-related medical concerns
• Assess for alcohol dependence
• Assess for mental health conditions
• Assess for alcohol-related behavioral problems
• Assess for readiness to change

Assess for Alcohol-Related Medical Concerns

• Blackouts
• Driving Under Influence
• Headaches
• Injuries
• Suicide ideation
• Accidents/falls
• Cognitive
• GI tract
• Diabetes
• High blood pressure

Assess for Alcohol Dependence

• Loss of control
• Preoccupation with use
• Repeated alcohol-related problems
• Tolerance or morning withdrawal
• Making rules to control drinking
• Compulsive use

Assess for Mental Health Conditions

• Anxiety
• Panic attacks
• Depression
• Physical or sexual abuse
• Bipolar disorders
• Axis II disorder (DSM – IV)

Assess for Alcohol-Related Behavioral Problems

• Academic performance below ability
• Receives incompletes for failing to turn in course assignments
• Dropping courses
• Getting into fights with roommates and friends
• Involvement with campus police

Readiness to Change Paradigm

Is the student considering reducing or stopping alcohol use?

Line progression first stage-Not considering change, second stage-Thinking about change, third stage-Ready to change, fourth stage-Taking action, fifth stage-Maintaining change

The student shows resistance between the first and second stage and ambivalence between the second and third stage

How to Implement Routine Screening and Assessment in a College Population

Student Health

• Administer alcohol use questions on AUDIT as part of new patient process.
• Have nurse ask alcohol question on every visit as part of vital signs check and document in record.
• Have all freshman complete a health history questionnaire that contains the AUDIT as part of routine admissions process.

How to Implement (continued)

Urgent Care and Emergency Departments

• Routine screening by nurse
• Routine BAL on all patients seen for trauma
• Availability of counselor to conduct brief intervention in Emergency Department

Historical document
Last reviewed: 9/23/2005