SESSION 4: AUDIT Screening
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In session 4:
Alcohol Use Disorders Identification Test (AUDIT)
The AUDIT: Interview Version
The AUDIT: Self-Report Version
Identification of a Drinking Problem
The World Health Organisation Alcohol Risk Zones
Alcohol Use Disorders Identification Test (AUDIT)
Why AUDIT?
The AUDIT screening test was developed by the World Health Organisation (WHO) as a simple method of screening for excessive drinking and to assist in the formulation of brief intervention. It can help in identifying excessive drinking as the cause of the presenting problem. It provides a framework for intervention with risky and high-risk drinkers to reduce or cease their alcohol consumption. It also helps to identify alcohol dependence and some specific consequences of risky drinking.
The AUDIT provides an accurate measure of risk across gender, age, and cultures. Its validity, brevity and flexibility make it the most widely used screening instrument around the world. The AUDIT is particularly designed for health-care practitioners and a range of health settings, but with suitable instructions it can be self-administered or used by lay groups.
What is AUDIT?
The standard AUDIT has only ten questions to which there is a choice of up to five answers in a tick-a-box format.
Domains and Item Content of the AUDIT
| Domains | Question Number | Item Content |
| Risky or Hazardous Alcohol Use | 1 | Frequency of drinking. |
| 2 | Typical quantity. | |
| 3 | Frequency of heavy drinking. | |
| Dependence Symptoms | 4 | Impaired control over drinking. |
| 5 | Increased salience of drinking. | |
| 6 | Morning drinking. | |
| High-Risk or Harmful Alcohol Use | 7 | Guilt after drinking. |
| 8 | Blackouts. | |
| 9 | Alcohol-related injuries. | |
| 10 | Others concerned about drinking. |
Administering the AUDIT
The AUDIT may be administered either as a self-report questionnaire or as an interview version (see examples of these two styles below and in Appendix C & Appendix D) or via computer and the Internet. Each method carries its own advantages and disadvantages that must be weighed up in light of time and cost constraints.
The cognitive capacities (e.g. literacy, forgetfulness) and the level of cooperation or defensiveness of the client should also be considered.
For some clients it is unnecessary to administer the complete AUDIT because they drink infrequently, moderately, or abstain entirely from alcohol.
If the client responds to Question 1 that no drinking has occurred during the last year, the interviewer may skip to Questions 9 and 10, the responses to which may indicate past problems.
A second opportunity exists to shorten the AUDIT. If the client scores 0 on Questions 2 and 3, the interviewer may skip to Question 10 because the client’s drinking has not exceeded the low-risk drinking limits.
If the provider’s responsibility is limited to just offering a brief intervention to clients who score positive and referring more severe cases to other services, the questionnaire method is preferable.
Examples of the AUDIT Interview version and the self-report version are shown below.
The AUDIT Interview questionnaire is also shown in Appendix C, while the self-report style is shown in Appendix D.
Facts, figures and fascinating information
|
Yes! It does go to your ‘head’ quicker. |
The AUDIT: Interview Version
Read questions as written. Record answers carefully. Begin the AUDIT by saying "Now I am going to ask you some questions about your use of alcoholic beverages during this past year." Explain what is meant by "standard drinks" and how to calculate them. Code answers in terms of "standard drinks".1. How often do you have a drink containing alcohol?
(0) Never (Skip to Qs 9 – 10)
(1) Monthly or less
(2) 2 to 4 times a month
(3) 2 to 3 times a week
(4) 4 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, 8 or 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
Skip to Question 9 and 10 if Total score for Questions 2 and 3 = 0
4. How often during the last year have you found that you were not able to stop drinking once you had started?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
5. How often during the last year have you failed to do what was normally expected from you because of drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
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?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
Record total of items 1 to 10 here ?
11. Do you think you presently have a problem with drinking?
(a) No
(b) Probably not
(c) Unsure
(d) Possibly
(e) Definitely
12. In the next 3 months, how difficult would you find it to cut down or stop drinking?
(a) Very easy
(b) Fairly easy
(c) Neither difficult nor easy
(d) Fairly difficult
(e) Very Difficult
Do not score questions 11 and 12. These questions provide an indication of the client’s ‘readiness to change’ or motivation to change their alcohol use. This will assist you in deciding what level of intervention.
The AUDIT: Self-Report Version
Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask you some questions about your use of alcohol. Your answers will remain confidential. We would like you to say how it really is.
QUESTIONS
|
1. How often do you have a drink containing alcohol? |
Never (Skip to Qs. 9 & 10) | Monthly or Less | 2-4 times a month | 2 to 3 times a week | 4 or more times a week | |
| Each one of these drinks is equivalent to one standard drink |
1 middy/pot standard beer |
1 schooner light beer |
1 glass
of wine 100 mls |
1 glass
of sherry or port 60 mls |
1 nip
of spirits 30 mls |
|
| 2. How many drinks containing alcohol do you have on a typical day when you are drinking? | 1 or 2 | 3 or 4 | 5 or 6 | 7 to 9 | 10 or more | |
| 3. How often do you have 6 or more drinks on one occasion? | Never | Less than monthly | Monthly | Weekly | 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? | Never | Less than monthly | Monthly | Weekly | Daily or almost daily | |
| 5. How often during the last year have you failed to do what was normally expected of you | Never | Less than monthly | Monthly | Weekly | Daily or almost daily | |
| 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 | Never | Less than monthly | Monthly | Weekly | Daily or almost daily | |
| 7. How often during the last year have you had a feeling of guilt or remorse after drinking? | Never | Less than monthly | Monthly | Weekly | Daily or almost daily | |
| 8. How often during the last year have you been unable to remember what happened the night before because of your drinking? | Never | Less than monthly | Monthly | Weekly | Daily or almost daily | |
| 9. Have you or someone else been injured because of your drinking? | No | Yes, but not in the last year | Yes, during the last year | |||
| 10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? | No | Yes, but not in the last year | Yes, during the last year | |||
| Total Items 1 to 10 >> | ||||||
| Score Qs 11 and 12 'a' to 'e' and write response in shaded box | ||||||
| 11. Do you think you presently have a problem with drinking? | (a) No |
(b) Probably not |
(c) Unsure |
(d) Possibly |
(e) Definitely |
|
| 12. In the next three months, how difficult would you find it to cut down or stop drinking? | (a) Very easy |
(b) Fairly easy |
(c) Neither difficult nor easy |
(d) Fairly difficult |
(e) Very difficult |
Scoring the AUDIT
The AUDIT is simple to score. Each of the questions has a range of responses and each response has a score ranging from 0 to 4. Questions are scored for the response from left to right. A total score of 40 is possible.
Higher scores indicate a greater likelihood of risky and high risk drinking and reflect a greater severity of alcohol problems and dependence as well as a greater need for more intensive treatment. Scores are calculated left to right as follows:
|
After you have recorded the client’s answers to these questions,
score each answer. Write the score in the box. |
What else can it tell us?
Additional information can be obtained from looking at the person’s answers to the individual questions. This is advisable. The questions can be divided into the following domains: - consumption, dependence, life problems and stages of changeConsumption : Questions 1-3
Refers to the level of the person’s alcohol consumption. A combined score of 4 or more classifies drinking as risky or hazardous. For most people who are screened in general health care settings or community surveys their scores will be under the cut-offs, but will tend to be higher in this domain than the others. Many people who are drinking at risky and high-risk levels will tend to have higher scores in the domains of Consumption and Life Problems and lower scores in the domain of Dependence. These people may be more suitable for brief interventions.Dependence: Questions 4-6
Enquiries about symptoms of dependence. A combined score of 4 or more indicates the emergence or existence of alcohol dependence. The score in this domain should be assessed in relation to the overall score. For example a score of 4 or more would usually indicate that the overall score would be 20 or above and warrant further evaluation for alcohol dependence. This may mean referral or additional assessment for more intensive intervention.
Life Problems: Questions 7-10
These questions enquire about problems the person has experienced that are related to drinking. A combined score of 4 or more indicates the existence of problems and is defined as high-risk or harmful. We may have a clear indication that alcohol related harm has already been experienced. Some people may give evidence of a past problem (i.e. "Yes, but not in the last year") and even if their drinking is not currently hazardous, it may indicate the need for reinforcing safe drinking and continued vigilance.Readiness to Change: Questions 11-12
These questions are in addition to the standard 10 question AUDIT and as such are not given a score to be calculated. Questions 11 and 12 will supply information about the person’s readiness or motivation to change their alcohol use and will assist the health practitioner in deciding the appropriate level of intervention.
People with the most positive outlook are those who think they have a problem with drinking and think reducing or stopping will be relatively easy. Brief counselling is appropriate for these people. Many others with risky or high-risk consumption will also respond to straightforward advice. People who are scoring higher on AUDIT will typically find it difficult to stop or cut down, particularly if they are ambivalent and at an early stage in the process of change.
Facts, figures and fascinating information
| In 1998, Australia was placed 19th on per capita consumption of pure alcohol (7.6 litres per person), compared with the Czech Republic on top with 160 litres per person |
Steps in Identification of a Drinking Problem
If a person has a total score of 8 or more on questions 1 to 10
1. Check the accuracy of the high scoring questions with the client.
2. Ask some additional questions to help you determine the person’s potential for alcohol dependence. The following questions may be helpful to both confirm accuracy and obtain more information:
- How many drinks did you have on your last drinking day - and on the previous occasion? (this is a good guide to the usual intake)
- Is there any time during the week when you regularly drink more than at other times (e.g. the weekend)? How much do you usually drink on these occasions? (This will indicate whether or not the person is a regular episodic-drinker.
- Do you skip meals because of your drinking?
- Do your hands shake in the morning after an evening’s drinking?
There are a number of assessment instruments and criteria for determining alcohol dependence. One of the more commonly used is the Short Alcohol Dependence Data Questionnaire (SADD) which is shown in Appendix O.
The ICD-10 and DSM-IV Criteria for the Alcohol Dependence syndrome are shown in Appendix L & Appendix M respectively.
Because the diagnosis and treatment of alcohol dependence has developed as a speciality within the mainstream of medical care, it is important to understand your agency's policies and procedures for referring veterans suspected of being alcohol dependent and who require further diagnosis and treatment.
The World Health Organisation Alcohol Risk Zones
Using the AUDIT, the AS+BI approach described here offers a simple way to provide each client with an appropriate intervention, based upon the level of risk. AUDIT results are classified into particular risk levels, or zones.
Brief interventions are those practices that aim to identify a real or potential alcohol problem and motivate an individual to do something about it.
The following table illustrates the general guidelines for World Health Organisation (WHO) assignment of risk levels based upon AUDIT scores.
The following table illustrates the risk levels and interventions connected to the AUDIT score.
| Risk Levels | Intervention | AUDIT Score |
| Zone I | Alcohol education | 0 - 7 |
| Zone II | Simple advice | 8 - 15 |
| Zone III | Simple advice plus Brief Counselling, and Continued Monitoring | 16 - 19 |
| Zone IV | Refer for diagnostic evaluation and treatment | 20 - 40 |
Risk Zone I — AUDIT scores between 0 and 7
This score generally indicated low-risk drinking. Although no formal intervention is required, alcohol education is appropriate for the following reasons:
- Contributes to the general awareness of alcohol risks in the community.
- It may be effective for clients who have experienced alcohol problems but who have already reduced their drinking levels; or whose circumstances may change.
- Could be effective for those clients who have minimised the extent of their drinking on the AUDIT questions.
Risk Zone II — AUDIT scores between 8 and 15
Scores in this zone are likely to be recorded by a significant proportion of clients. They indicate alcohol use in excess of the low-risk guidelines. Persons in Zone II generally would be drinking at risky or hazardous levels and would be at moderate risk of alcohol-related harm. This zone however may also include clients experiencing actual harm and low levels of dependence. Generally, simple advice and information on the alcohol guidelines and risk factors would be appropriate intervention.Risk Zone III — AUDIT scores between 16 and 19
This zone indicates risky drinking and problems related to higher levels of consumption. This score indicates a pattern of consumption that is already causing harm to the drinker who may also have symptoms of dependence. Clients in this zone may be managed by a combination of simple advice, brief counselling, and continued monitoring. Follow-up and referral, in some cases, may be necessary.Risk Zone IV — AUDIT scores in excess of 20 and where scores on questions 4, 5 and 6 are equal or greater than 4.
Scores in this zone indicate that the person falls into the high-risk category of alcohol-related harm. Clients in this zone are likely to be alcohol dependent and require more intensive intervention. Service providers should note that dependence varies along a continuum of severity and might be clinically significant at lower AUDIT scores. Clients in this zone should be referred to specialist services to consider withdrawal, pharmacotherapy and other more intensive treatments.
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