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...
Quantity, frequency, and binge drinking questions seem to have the best psychometric properties to detect high-risk college drinking.
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.
Just asking the question may change alcohol use and norms.
Context! Method of administration! Skills of the provider! All are critical factors!
No current biological or laboratory markers are sufficiently sensitive for routine screening in college students.
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)
**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.
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
