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    AUDIT-C for Alcohol Use

    Identifies at-risk drinkers (i.e., binge drinking) who may not be alcohol-dependent.
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    When to Use
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    Why Use
    • The 4-item CAGE questionnaire is the briefest effective screening test for lifetime alcohol abuse/dependence, but it is not sensitive for detecting heavy drinking and does not distinguish between active and past problem drinking. The AUDIT-C is more effective in identifying this population.
    • AUDIT-C can be included among standard history questions or general health intake questionnaires in primary care, emergency department, psychiatric and inpatient hospital settings.
    • Other at-risk populations where AUDIT-C or another alcohol screening assessment is indicated include:
      • Pregnant women
      • College students
      • Arrested and incarcerated persons, especially DWI and domestic violence offenders
    • AUDIT-C is a 3-item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorders.
    • The AUDIT-C is a modified, shortened version of the 10-question AUDIT instrument. Its briefer design makes it more practical for incorporation into routine patient interviews or health history questionnaires in a primary care setting.
    • AUDIT-C is a screening tool. An abnormal or positive screening result may thus “raise suspicion” about the presence of an alcohol use problem, while a normal or negative result should suggest a low probability of an alcohol use problem. Assessment for purposes of diagnosis occurs in subsequent stages of evaluation.
    • Physicians often overlook alcohol problems in patients. (Kitchens JM 1994)
    • Simply asking patients how much they drink often leads to an estimate lower than the actual number of alcoholic drinks per day.
    • Alcohol disorders are treatable despite physician bias otherwise. (Kitchens JM 1994)
    • Without identification and treatment alcohol problems lead to significant morbidity and mortality:
      • Alcohol is a major factor in suicides, homicides, violent crimes, and fatal motor vehicle accidents. Nearly 88,000 people die from alcohol-related causes annually, making it the third leading preventable cause of death in the United States. (Centers for Disease Control and Prevention 2014)
      • Alcohol is primarily or secondarily implicated in a large number of medical problems.
      • The mortality rate in those who drink six or more drinks per day is 50% higher than the rate in matched controls. (Klatsky AL 1992)

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    Next Steps
    Evidence
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    Advice

    If a clinician suspects that the patient is minimizing his or her alcohol use, or if a patient’s score is near the cutoff, one may consider utilizing a more lengthy screening test to better determine the nature and extent of the problem. (The Physicians' Guide to Helping Patients With Alcohol Problems 1995)

    Other validated tests for further assessment include:

    • Michigan Alcoholism Screening Test (MAST)
    • Alcohol Use Disorders Identification Test (AUDIT)

    Management

    • When screening results are positive, the patient should be referred for further evaluation and treatment of an alcohol use problem.
    • This will vary based on available resources but is ideally to an addiction psychiatrist, psychologist, or addiction treatment program.

    Critical Actions

    In any hospital setting where access to alcohol may be limited, always monitor for signs/symptoms of alcohol withdrawal, even in patients who have not screened positive for an alcohol problem.

    Formula

    Addition of the selected points.

    Facts & Figures

    The AUDIT-C (Alcohol Use Disorder Identification Test) quantifies alcohol misuse, based on 3 questions posed to patients about their consumption habits. It was adapted from the longer AUDIT, which is mainly used in primary care settings.

    Score interpretation:

    • Males: Scores ≥4 suggest alcohol misuse.
    • Females: Score ≥3 suggest alcohol misuse.
    • Higher score correlates with greater severity of alcohol misuse.

    Evidence Appraisal

    Original article:

    The AUDIT was developed by the World Health Organization (WHO) as a simple method of screening for excessive drinking and to assist in brief assessment. It was first published as a manual in 1989, and most recently updated in 2001. The AUDIT-C was developed in 1998 due to the recognition that the 10-question length of the AUDIT made it unlikely that primary providers would incorporate it into routine patient interviews or general health history questionnaires. In studying a VA primary care setting, they found that although the full AUDIT performed better than AUDIT-C for detecting active alcohol abuse or dependence (0.811 vs 0.786;P<.001), the 2 questionnaires performed similarly for detecting heavy drinking and/or active abuse or dependence (0.880 vs 0.881). This validated the AUDIT-C for use in detecting heavy drinking and active abuse/dependence.

    Validation article (Bradley 2007):

    This was a cross-sectional validation study that compared several types of alcohol screening questionnaires with standardized interviews in a primary care setting. The AUDIT-C, full AUDIT, self-reported risky drinking, AUDIT question #3, and an augmented CAGE questionnaire were compared with an interview primary reference standard of alcohol misuse, defined as a DSM, 4th ed. alcohol use disorder and/or drinking above recommended limits in the past year. The results indicated that AUDIT-C was an effective screening test for alcohol misuse in this primary care sample, with optimal screening thresholds for alcohol misuse among men (≥4) and women (≥3).

    Validation article (Frank 2008):

    The first validation article utilized primarily a CaucasianWhite population. This article evaluated the validity of the AUDIT-C among primary care patients from an expanded group of racial subgroups including CaucasiansWhites, African Americans, and Hispanics. Areas under the receiver operating curve (AuROCs) evaluated overall AUDIT-C performance in the 3 racial/ethnic groups compared to diagnostic interviews for alcohol misuse. The overall performance of the AUDIT-C was excellent in all 3 racial/ethnic groups as reflected by high AuROCs.

    Literature

    Dr. Katharine Bradley

    About the Creator

    Katharine Bradley, MD, MPH, is a senior Investigator at the Group Health Research Institute and concentrates on identifying and addressing unhealthy alcohol use in primary care. She is currently leading the NIH's Alcohol Abuse and Alcoholism Study. Formerly, Dr. Bradley worked at the Veterans Affairs (VA) Puget Sound Health Care System, where she practiced primary care for over 15 years.

    To view Dr. Katharine Bradley's publications, visit PubMed