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Jonas DE, Garbutt JC, Brown JM, et al. Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jul. (Comparative Effectiveness Reviews, No. 64.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse

Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse [Internet].

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Appendix FScreening Instruments

Instrument NameDescriptionNo. Items/ Questions

Time to Administer		Scoring Notes
ARPSIncludes items in the following: domains:

presence of medical and psychiatric conditions (14 items);
symptoms of disease (12 items);
smoking behavior (1 item);
medication use (17 items),
physical function and health status (6 items);
quantity and frequency of alcohol use (2 items);
episodic heavy drinking (2 items);
symptoms of alcohol abuse and dependence (4 items);
driving after drinking (1 item), and
gender (1 item).		60
16 min		Developed for older adults;

Complex scoring algorithm;

Classifies as harmful, hazardous, or nonhazardous
ASSISTInstrument is a brief interview about alcohol, tobacco products, and other drugs; Alcoholic beverages (beer, wine, spirits, etc.) are a subset of each questionnaire item, which each lists a series of substances for potential abuse screening.

Lifetime use (Response Choices: No=0; Yes=3)
Use in past three months (Response Choices: Never=0; Once or Twice=2; Monthly=3; Weekly=4; Daily or Almost Daily=6)
During the past three months, strong desire or urge to use (Response Choices: Never=0; Once or Twice=3; Monthly=4; Weekly=5; Daily or Almost Daily=6)
During the past three months, how often use led to health, social, legal or financial problems (Response Choices: Never=0; Once or Twice=4; Monthly=5; Weekly=6; Daily or Almost Daily=7)
During the past three months, how often failed to do what was normally expected because of use (Response Choices: Never=0; Once or Twice=5; Monthly=6; Weekly=7; Daily or Almost Daily=8)
Friend or relative or anyone else expressed concern about use (Response choices: No, Never=0; Yes, in the past 3 months=6; Yes, but not in the past 3 months=3)
Ever tried and failed to control, cut down or stop using (Response choices: No, Never=0; Yes, in the past 3 months=6; Yes, but not in the past 3 months=3)
Ever used any drug by injection Response choices: No, Never=0; Yes, in the past 3 months=2; Yes, but not in the past 3 months=1)		8
2-4 min		Add up the scores received for questions 2 through 7 inclusive. Does not include the results from either Q1 or Q8..

Score 0-10: no intervention; risk level low

Score 11-26: receive brief Intervention; risk level moderate

Score 27+ more intensive treatment; risk level high. Further assessment and more intensive treatment may be provided by the health professional(s)
within primary care setting, or, by a specialist drug and alcohol treatment service when available.
AUDIT
  1. How often do you have a drink containing alcohol?
    0.

    NEVER

    1.

    MONTHLY OR LESS

    2.

    TWO TO FOUR TIMES A MONTH

    3.

    TWO TO THREE TIMES A WEEK

    4.

    FOUR OR MORE TIMES A WEEK

  2. How many drinks containing alcohol do you have on a typical day when you are drinking?
    0.

    1 OR 2

    1.

    3 or 4

    2.

    5 OR 6

    3.

    7 TO 9

    4.

    10 OR MORE

  3. How often do you have six or more drinks on one occasion?
    0.

    NEVER

    1.

    LESS THAN MONTHLY

    2.

    MONTHLY

    3.

    WEEKLY

    4.

    DAILY OR ALMOST DAILY

  4. How often during the last year have you found that you were not able to stop drinking once you had started? (same options as #3)
  5. How often during the last year have you failed to do what was normally expected from you because of drinking? (same options as #3)
  6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? (same options as #3)
  7. How often during the last year have you had a feeling of guilt or remorse after drinking? (same options as #3)
  8. How often during the last year have you been unable to remember what happened the night before because you have been drinking? (same options as #3)
  9. Have you or someone else been injured as a result of your drinking?
    0.

    NO

    1.

    YES, BUT NOT IN THE LAST YEAR

    2.

    YES, DURING THE LAST YEAR

  10. Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down? (same options as #9)
10

2-5 min		Scoring: ≥8 considered a positive screen for hazardous or harmful drinking.

In general:
Scores between 8 and 15 are most appropriate for simple advice focused on the reduction of hazardous drinking;

Scores between 16 and 19 suggest brief counseling and continued monitoring;

Scores of 20 and above clearly warrant further diagnostic evaluation for alcohol dependence.
AUDIT-C
  1. How often do you have a drink containing alcohol?
    0.

    NEVER

    1.

    MONTHLY OR LESS

    2.

    TWO TO FOUR TIMES A MONTH

    3.

    TWO TO THREE TIMES A WEEK

    4.

    FOUR OR MORE TIMES A WEEK

  2. How many drinks containing alcohol do you have on a typical day when you are drinking?
    0.

    1 OR 2

    1.

    3 or 4

    2.

    5 OR 6

    3.

    7 TO 9

    4.

    10 OR MORE

  3. How often do you have six or more drinks on one occasion?
    0.

    NEVER

    1.

    LESS THAN MONTHLY

    2.

    MONTHLY

    3.

    WEEKLY

    4.

    DAILY OR ALMOST DAILY

3

1-2 min		In men, ≥4 points is considered positive for alcohol misuse;
in women, ≥3 points is considered positive.
CAGE
C.

have you ever felt you should cut down on your drinking?

A.

have people annoyed you by criticizing your drinking?

G.

have you ever felt bad or guilty about your drinking?

E.

eye-opener: have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

4

1 min		Score 1 point for each ‘yes’ response; range 0–4.

Positive score ≥2.
LAST
  1. Are you always able to stop drinking when you want to?
  2. Have you ever felt you should cut down on your drinking?
  3. Have you ever felt bad or guilty about your drinking?
  4. Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking?
  5. Have you ever gotten into trouble at work because of drinking?
  6. Have you ever been told you have liver trouble? Cirrhosis?
  7. Have you ever been in a hospital because of drinking?
7

1-2 mins		Score 1 point for answer of “no” on question 1; score 1 point for each ‘yes on questions 2-7.’

Two or more points are indicative of alcohol dependence or abuse
MAST*All items are yes/no questions
  1. Do you feel you are a normal drinker? (“normal” - drink as much or less than most other people)?
  2. Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?
  3. Does any near relative or close friend ever worry or complain about your drinking?
  4. Can you stop drinking without difficulty after one or two drinks?
  5. Do you ever feel guilty about your drinking?
  6. Have you ever attended a meeting of Alcoholics Anonymous (AA)?
  7. Have you ever gotten into physical fights when drinking?
  8. Has drinking ever created problems between you and a near relative or close friend?
  9. Has any family member or close friend gone to anyone for help about your drinking?
  10. Have you ever lost friends because of your drinking?
  11. Have you ever gotten into trouble at work because of drinking?
  12. Have you ever lost a job because of drinking?
  13. Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?
  14. Do you drink before noon fairly often?
  15. Have you ever been told you have liver trouble such as cirrhosis?
  16. After heavy drinking have you ever had delirium tremens (D.T.'s), severe shaking, visual or auditory (hearing) hallucinations?
  17. Have you ever gone to anyone for help about your drinking?
  18. Have you ever been hospitalized because of drinking?
  19. Has your drinking ever resulted in your being hospitalized in a psychiatric ward?
  20. Have you ever gone to any doctor, social worker, clergyman or mental health clinic for help with any emotional problem in which drinking was part of the problem?
  21. Have you been arrested more than once for driving under the influence of alcohol?
  22. Have you ever been arrested, even for a few hours, because of other behavior while drinking?
22

8-15 min		This quiz is scored by allocating 1 point to each ‘yes’ answer -- except for questions 1 and 4, where 1 point is allocated for each ‘no’ answer -- and totalling the responses.

≥5 is a positive screen for possible alcoholism
MAST-GAll items are yes/no questions
  1. After drinking have you ever noticed an increase in your heart rate or beating in your chest?
  2. When talking to others, do you ever underestimate how much you actually drank?
  3. Does alcohol make you sleepy so that you often fall asleep in your chair?
  4. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn't feel hungry?
  5. Does having a few drinks help you decrease your shakiness or tremors?
  6. Does alcohol sometimes make it hard for you to remember parts of the day or night?
  7. Do you have rules for yourself that you won't drink before a certain time of the day?
  8. Have you lost interest in hobbies or activities you used to enjoy?
  9. When you wake up in the morning, do you ever have trouble remembering part of the night before?
  10. Does having a drink help you sleep?
  11. Do you hide your alcohol bottles from family members?
  12. After a social gathering, have you ever felt embarrassed because you drank too much?
  13. Have you ever been concerned that drinking might be harmful to your health?
  14. Do you like to end an evening with a night cap?
  15. Did you find your drinking increased after someone close to you died?
  16. In general, would you prefer to have a few drinks at home rather than go out to social events?
  17. Are you drinking more now than in the past?
  18. Do you usually take a drink to relax or calm your nerves?
  19. Do you drink to take your mind off your problems?
  20. Have you ever increased your drinking after experiencing a loss in your life?
  21. Do you sometimes drive when you have had too much to drink?
  22. Has a doctor or nurse ever said they were worried or concerned about your drinking?
  23. Have you ever made rules to manage your drinking?
  24. When you feel lonely, does having a drink help?
24

10 min		This quiz is scored by allocating 1 point to each ‘yes’ answer ;

≥5 is a positive screen for possible alcoholism
NET
N.

normal drinker: do you feel you are a normal drinker?

E.

eye-opener question from CAGE

T.

tolerance: how many drinks does it take to make you feel high? (>2 indicates tolerance)

3
1 min		Score 1 point each for not normal or eye openers and 2 points for tolerance; range 0–4
shARPSIncludes items in the following: domains:

presence of medical and psychiatric conditions (8 items);
symptoms of disease (7 items);
medication use (11 items),
physical function and health status (1 item);
quantity and frequency of alcohol use (2 items);
episodic heavy drinking (1 item);
symptoms of alcohol abuse and dependence (1 items); and
driving after drinking (1 item)		32

2-5 min		Developed for older adults;

Complex scoring algorithm;

Classifies as harmful/hazardous, or nonhazardous
Single question: 12 months
 (NIAAA-recommended)		“How many times in the past year have you had X or more drinks in a day?” (X = 5 for men and 4 for women).1

1 min		≥1 is a positive screen
Single question: 3 months
 (often called SASQ)		“When was the last time you had more than X drinks in 1 day?,” where X was 4 for women and X was 5 for men

Alternate wording:
“On any single occasion during the past 3 months, have you had more than 5 drinks containing alcohol?”		1

1 min		Positive if answer is within past 3 months.

Positive if answer is yes.
SMAST
  1. Do you feel you are a normal drinker?
  2. Do your spouse, parents or other close relative worry or complain about your drinking?
  3. Do you ever feel guilty about your drinking?
  4. Do friends or relatives think you are a normal drinker?
  5. Are you able to stop drinking when you want to?
  6. Have you ever attended a meeting of Alcoholics Anonymous?
  7. Has your drinking ever caused problem between you, a spouse, parents or close relative?
  8. Have you ever got into trouble at work because of drinking?
  9. Have you ever neglected your obligations your family or your work for 2 or more days in a row because you were drinking?
  10. Have you ever gone to anyone for help about your drinking?
  11. Have you ever been in a hospital because of drinking?
  12. Have you ever been arrested for drunk driving or driving after drinking?
  13. Have you ever been arrested, however short a time, because of drinking?
13

5 min		This quiz is scored by allocating 1 point to each ‘yes’ answer;

≥2 is a positive screen for possible alcoholism
SMAST-G
  1. When talking to others, do you ever underestimate how much you actually drank?
  2. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn't feel hungry?
  3. Does having a few drinks help you decrease your shakiness or tremors?
  4. Does alcohol sometimes make it hard for you to remember parts of the day or night?
  5. Do you usually take a drink to relax or calm your nerves?
  6. Do you drink to take your mind off your problems?
  7. Have you ever increased your drinking after experiencing a loss in your life?
  8. Has a doctor or nurse ever said they were worried or concerned about your drinking?
  9. Have you ever made rules to manage your drinking?
  10. When you feel lonely, does having a drink help?
10

NR		This quiz is scored by allocating 1 point to each ‘yes’ answer;

≥2 is a positive screen for possible alcoholism
T-ACE
T.

tolerance: how many drinks does it take to make you feel high? (>2 indicates tolerance)

A.

have people annoyed you by criticizing your drinking?

C.

have you ever felt you should cut down on your drinking?

E.

eye-opener: have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

4

1 min		Score 2 points for tolerance; 1 point for others; range 0–5; threshold for positive score ≥2
TWEAK
T.

tolerance: how many drinks can you hold (‘hold’ version >5 indicates tolerance) or how many drinks can take before you begin to feel the effects (‘high’ version >2 indicates tolerance)

W.

have close friends or relatives worried or complained about your drinking in the last year?

E.

eye-openers: do you sometimes take a drink in the morning when you first get up?

A.

amnesia: has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?

K.

kut down: do you sometimes feel the need to cut down on your drinking?

5

<2 min		Score 2 points each for first 2 items and 1 point each for last 3; range 0–7;

positive score ≥2
*

The original MAST included 25 questions and used a more complex scoring method; the version presented here represents the revised version used in practice today.

  • ARPS
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  • ASSIST
    WHO ASSIST Working Group. The Alcohol Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction. 2002;97(9):1183–1194. [PubMed: 12199834]
    Humeniuk RE, Ali RA, Babor TF, Farrell M, Formigoni ML, Jittiwutikarn J, de Larcerda R Boerngen, Ling W, Marsden J, Monteiro M, Nhiwhatiwa S, Pal H, Poznyak V, Simon S. Validation of the Alcohol Smoking and Substance Involvement Screening Test (ASSIST). Addiction. 2008;103(6):1039–1047. [PubMed: 18373724]
  • AUDIT
    Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption – II. Addiction. 1993;88:791–804. [PubMed: 8329970]
  • AUDIT-C
    Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998 Sep 14;158(16):1789–95. [PubMed: 9738608]
  • CAGE
    Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry. 1974;131:1121–1123. [PubMed: 4416585]
    Ewing JA. Detecting alcoholism: The CAGE questionnaire. JAMA. 1984;252(14):1905–1907. [PubMed: 6471323]
  • LAST
    Rumpf H, Hapke U, Hill A, John U. Development of a screening questionnaire for the general hospital and general practices. Alcohol Clin Exp Res. 1997;21(5):894–898. [PubMed: 9267540]
  • MAST
    Selzer ML. The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry. 1971;127:1653–1658. [PubMed: 5565851]
  • MAST-G
    Blow FC, Brower KJ, Schulenberg JE, Demo-Dananberg LM, Young JP, Beresford TP. The Michigan Alcoholism Screening Test – Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcoholism: Clinical and Experimental Research. 1992;16:372.
  • NET
    Bottoms S, Martier S, Sokol R. Refinements in screening for risk drinking in reproductive-aged women: the “NET” results. Alcohol Clin Exp res. 1989;13:339.
  • NIAAA
    National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician's Guide. Washington, DC: U.S. Department of Health and Human Services; 2005.
  • SMAST
    Selzer ML, Vinokur A, van Rooijen L. A self-administered Short Michigan Alcoholism Screening Test (SMAST). J Stud Alcohol. 1975;36(1):117–126. [PubMed: 238068]
  • SMAST-G
    Blow FC, Gillespie BW, Barry KL, Mudd SA, Hill EM. Brief screening for alcohol problems in the elderly populations using the Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G). Alcohol Clin Exp Res. 1998;22(Suppl):131A.
  • T-ACE
    Sokol RJ, Martier SS, Ager JW. The T-ACE questions: practical prenatal detection of risk-drinking. Am J Obstet Gynecol. 1989;160:863–870. [PubMed: 2712118]
  • TWEAK
    Chan AWK, Pristach EA, Welte JW, Russell M. Use of the TWEAK test in screening for alcoholism/heavy drinking in three populations. Alcohol Clin Exp res. 1993;17:1188–1192. [PubMed: 8116829]
  • SASQ
    Williams RH, Vinson DC. Validation of a single question screen for problem drinking. Journal of Family Practice. 2001;50:307–312. [PubMed: 11300981]
  • shARPS
    Moore AA, Beck JC, Babor TF, Hays RD, Reuben DB. Beyond alcoholism: identifying older, at-risk drinkers in primary care. J Stud Alcohol. 2002;63:316–324. [PubMed: 12086132]

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