Appendix II: Common Screening Tools for Identifying Substance and Alcohol Problems
Updated November 2007
COMMON SCREENING TOOLS FOR IDENTIFYING SUBSTANCE AND ALCOHOL PROBLEMS*
*Except for the TICS, the clinical utility of the screening instruments listed in this appendix was based on their use in identifying alcohol problems only.
I. SINGLE ALCOHOL SCREENING QUESTION
Target Population: Adults
This single question about the last episode of heavy drinking has clinically useful sensitivity and specificity in detecting hazardous drinking and alcohol use disorders.
|How many times in the past year have you had X or more drinks in 1 day? where X = 4 for women and X = 5 for men, and one or more heavy drinking days in the past year is considered a positive screen.|
|Reprinted from the National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide, Updated 2005 Edition. Available at:
II. TWO-QUESTION SCREENS
Target Population: Adults
Short screening instruments are useful in the primary care setting and have been shown to identify patients with substance use problems/addiction as effectively as longer screens.
The combination of the following two questions has a sensitivity of 91% in identifying problem drinkers:
|1. Have you ever had a drinking problem?
2. When was your last drink?
|Reprinted with permission from Cyr MG, Wartman SA. The effectiveness of routine screening questions in the detection of alcoholism. JAMA 1988;259:51-54. Copyright © 1988 American Medical Association. All rights reserved. [PubMed]|
A more recent two-item screen, the Two-Item Conjoint Screen (TICS), is easy to administer, has been shown to identify 80% of current substance abusers, and is particularly sensitive to polysubstance use disorders:
|1. In the last year, have you ever drunk or used drugs more than you meant to?
2. Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
≥1 positive may be suggestive of a problem
|Reprinted with permission from Brown RL, Leonard T, Saunders LA, et al. A two-item conjoint screen for alcohol and other drug problems. J Am Board Fam Pract 2001;14:95-106. Copyright © 2001, JABFM Online by American Board of Family Medicine. [PubMed]|
III. CAGE-AID (CAGE – Adapted to Include Drugs)
Target Population: Adults and Adolescents >16
CAGE is a short screen that is essentially nonjudgmental and non-confrontational. The CAGE questionnaire has been shown to be more effective if introduced with an open-ended statement, such as “Please tell me about your drinking.”1 Using open-ended questions, such as “have you ever,” helps reveal present or past use, and it can be modified by using the phrase drinking or substance use instead of just drinking (CAGE-AID).2
The validity of CAGE-AID is less extensively studied, but many clinicians think it is a reliable tool. Limitations to the CAGE are that it does not distinguish between active and inactive problems and has not been validated for identifying hazardous or harmful drinking.3
|(1) Have you ever felt the need to cut down on your use of alcohol or drugs?
(1) Has anyone annoyed you by criticizing your use of alcohol or drugs?
(1) Have you ever felt guilty because of something you’ve done while drinking or using drugs?
(1) Have you ever taken a drink or used drugs to steady your nerves or get over a hangover (eye-opener)?
A total of ≥2 may be suggestive of a problem
|Reprinted from Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: Criterion validity in a primary care practice. Wis Med J 1995;94:135-140. [PubMed]|
Target Population: Adults
TWEAK was developed and validated to screen for risk drinking in pregnant women. It also has been used to screen for harmful drinking in the general population for both inpatients and outpatients. TWEAK is intended to identify individuals who need more thorough screening for alcohol problems.4
|(2) Tolerance: How many drinks can you hold? (>5 = positive)
(2) Worry: Have close friends or relatives worried or complained about your drinking?
(1) Eye-opener: Have you ever taken a drink to steady your nerves or get over a hangover?
(1) Amnesia: Has a close friend or relative ever told you about things you said or did when drinking that you could not remember?
(1) Kut down: Have you ever felt the need to cut down on your use of alcohol?
A score of ≥3 is suggestive of harmful drinking
|Reprinted from Russell M. New assessment tools for drinking in pregnancy: T-ACE, TWEAK, and others. Alcohol Health Res World 1994;18:55-61.|
V. AUDIT C (QUESTIONS 1,2,3 ONLY) AND AUDIT (QUESTIONS 1-10)
Target Population: Adults
AUDIT C is an initial screen shown to discriminate effectively between patients with a history of drinking problems and those without such a history, including hazardous drinking. Its brevity ensures that clinicians will remember it, and administration time is minimal. A positive total score is an indication to administer the remaining questions on the full AUDIT or the CAGE to determine the presence of a more severe alcohol problem.5,6
AUDIT includes questions on amount, frequency, dependence, and problems caused by alcohol. It is used to identify individuals who may have more serious drinking problems and who could benefit from referral to a treatment program or counseling. It is relatively free of gender and cultural bias.7
|1. How often do you have a drink containing alcohol?
(0) Never (1) Monthly or less (2) 2 to 4 times a month (3) 2 to 3 times a week (4) ≥4 times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
3. How often do you have ≥6 drinks on one occasion?
4. How often during the last year have you found that you were not able to stop drinking once you had started?
5. How often during the last year have you failed to do what was normally expected from you because of drinking?
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?
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
9. Have you or someone else been injured as a result of your drinking?
10. Has a relative, friend, or a physician, or other healthcare worker been concerned about your drinking or suggested you cut down?
A score of ≥8 indicates a strong likelihood of hazardous or harmful alcohol consumption
|Reprinted from Babor TF, de la Fuente JR, Saunders J, et al. AUDIT: The Alcohol Use Disorders Identification Test. Guidelines for Use in Primary Health Care, 2nd ed. Geneva, Switzerland, 2001:1-40. Available at: http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf|
VI. ALCOHOL-RELATED TRAUMA QUESTIONNAIRE
Target Population: Adults >18
This questionnaire was developed for earlier detection of problem drinking in ambulatory patients compared with the results of laboratory results, which seem to have high sensitivity in more chronic alcoholics only.
|Since your 18th birthday:
(1) Have you had any fractures or dislocations to your bones or joints?
(1) Have you been injured in a road traffic accident?
(1) Have you injured your head?
(1) Have you been injured in an assault or fight (excluding injuries during sports)?
(1) Have you been injured after drinking?
Result: 0 – low probability
|Reprinted with permission from Skinner HA, Holt S, Schuller R, et al. Identification of alcohol abuse using laboratory tests and a history of trauma. Ann Intern Med 1984;101:847-851. [PubMed]|
VII. ALCOHOL, SMOKING AND SUBSTANCE INVOLVEMENT SCREENING TEST (ASSIST)
Target Population: Adolescents and Adults
ASSIST is a concise screening questionnaire developed by WHO. The study and analysis found that the ASSIST could differentiate between patients who: 1) were low-risk substance users or abstainers, 2) were at risk for, or already had, substance use problems, or were at risk for developing dependence, or 3) were dependent on a substance.8
Reprinted from Henry-Edwards S, Humeniuk R, Ali R, et al. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): Guidelines for Use in Primary Care. Geneva, World Health Organization, 2006. Available at: http://www.who.int/substance_abuse/activities/assist_v3_english.pdf
1. Steinweg DL, Worth H. Alcoholism: The keys to the CAGE. Am J Med 1993;94:520-523. [PubMed]
2. Hinkin CH, Castellon SA, Dickson-Fuhrman E, et al. Screening for drug and alcohol abuse among older adults using a modified version of the CAGE. Am J Addict 2001;10:319-326. [PubMed]
3. National Institute on Alcohol Abuse and Alcoholism. CAGE Questionnaire. Available at: http://pubs.niaaa.nih.gov/publications/Assesing Alcohol/InstrumentPDFs/16_CAGE.pdf
4. National Institute on Alcohol Abuse and Alcoholism. TWEAK. Available at: http://pubs.niaaa.nih.gov/publications/Assesing Alcohol/InstrumentPDFs/74_TWEAK.pdf
5. Bush K, Kivlahan DR, McDonell MB, et al. The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998;158:1789-1795. [PubMed]
6. Gordon AJ, Maisto SA, McNeil M, et al. Comparisons of abbreviated instruments to detect hazardous drinking in a large primary care sample. J Fam Pract 2001;50:313-320. [PubMed]
7. National Institute on Alcohol Abuse and Alcoholism. Alcohol Use Disorders Identification Test (AUDIT). Available at: http://pubs.niaaa.nih.gov/publications/Assesing Alcohol/InstrumentPDFs/14_AUDIT.pdf
8. Henry-Edwards S, Humeniuk R, Ali R, et al. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): Guidelines for Use in Primary Care. Geneva, World Health Organization, 2006. Available at: http://www.who.int/substance_abuse/activities/assist_v3_english.pdf