Which questionnaire would the nurse use to assess at risk drinking of alcohol in a pregnant patient?

Brief Screening

Every patient should be asked about alcohol use. Because drinking is normative in the United States, if drinking is denied, it is useful to determine if the patient used to drink but has stopped because of a past problem. After determining if a patient currently uses any alcohol, the simplest strategy is to ask about the number of heavy drinking days in the past year, where heavy drinking is defined as more than five drinks for men and more than four drinks for women in one day. If that threshold is reached (0 = negative screen; >0 = positive screen), which corresponds to at-risk or hazardous drinking, then further evaluation of alcohol-related problems is indicated through the use of screening instruments, such as the three-item AUDIT-C, in the following. A standard drink is the same amount of alcohol contained in different volumes of alcoholic beverages (Box 2).

The Alcohol Use Disorders Identification Test (AUDIT) (Table 1) is a 10-item screen developed by the World Health Organization. Given its length, the AUDIT can be used as a self-report screener that patients can fill out in the waiting area before seeing the clinician. The minimum score is 0 and the maximum score is 40. A score of 8 or more for men or 4 or more for women, adolescents, and persons older than 65 years, like a positive endorsement of any heavy drinking days, indicates the need for further evaluation of alcohol use and an increased risk of an alcohol use disorder. For brevity, the AUDIT-C, a truncated version of the AUDIT consisting of the first three AUDIT questions focused on alcohol consumption, can be used as a part of a waiting-room health history form. A score of 6 or more for men or 4 or more for women on the AUDIT-C indicates a need for further evaluation.

Asking about alcohol consumption during a routine clinical interview is best bundled with other questions about lifestyle and health, such as diet, smoking, and exercise. In addition to giving the patient a pre-examination questionnaire to fill out such as the AUDIT, another screening strategy is to ask the CAGE questions (Box 3) during the clinical examination. A positive answer to any of these questions also indicates the need for further evaluation of alcohol use. Two or more CAGE questions answered affirmatively identifies a patient at high risk for alcohol dependence. Because the CAGE screens for consequences, it is not as sensitive for risky drinking.

There are other question sets that are more sensitive than the CAGE in specific demographic subsets, and these can also be easily asked during a routine history. The five-item TWEAK questionnaire (Table 2) may be a more optimal screening questionnaire for identifying women (including pregnant women) with risky drinking or alcohol use disorders in racially mixed populations. The CRAFFT (Box 4) is a six-item question set that has high sensitivity in screening adolescents for alcohol and other substance-abuse problems. For patients older than 65 years, the Short Michigan Alcoholism Screening Test—Geriatric (S-MAST-G) (Box 5) is useful in identifying those at risk for alcohol problems, because these patients might not need the same volumes of alcohol intake as others to develop alcohol-related problems. To complete the initial screening, one should compute the average number of drinks per week by multiplying the days per week on average that the patient drinks by the number of drinks consumed on a typical drinking day.

4.14.3 Alcohol Biomarkers and AUDIT

AUDIT score is capable of providing a history of alcohol use in the past year, whereas no alcohol biomarker has this capability. Most alcohol biomarkers can provide information regarding recent use of alcohol, and hair testing may provide information up to a few months. Nevertheless, self-reported alcohol use such as AUDIT score has limitations. Patients may be reluctant to provide an accurate representation of past drinking history due to the social stigma associated with heavy consumption of alcohol. Therefore, AUDIT score and alcohol biomarkers may be complimentary in identifying patients who may be consuming excess alcohol. The validity of self-reporting may be improved if it is used in combination with a laboratory test such as alcohol biomarker. Using an AUDIT cutoff score of 8 and CDT cutoff scores of 20 U/L in males and 27 U/L in females, Hermansson et al. reported that out of 570 subjects who participated in a workplace health examination, 105 subjects (18.4%) screened positive according to AUDIT score, CDT cutoff, or both. The AUDIT score varied between 8 and 12 in subjects who screened positive by AUDIT, whereas CDT levels were 22–65 U/L in males and 30–36 U/L in females who screened positive. If GGT was included, then 125 subjects (22%) screened positive. However, if only AUDIT was used in the screening process, the proportion of all positives would have decreased by nearly half. The authors concluded that AUDIT and CDT are complementary for alcohol screening in a routine workplace health examination [66]. Wurst et al. found that self-reported ethanol intake in the past 28 days correlated with AUDIT score, with the direct ethanol metabolite (ethyl glucuronide and ethyl sulfate), and with MCV. However, results from biomarker tests could indicate cases of under- as well as overreporting of alcohol consumption [67]. In another report, the authors commented that although hair ethyl glucuronide correlated with AUDIT score, hair ethyl glucuronide identified 10 more cases of positive alcohol [68].

Case Report 4.3

A 39-year-old woman who initially presented with bleeding gums due to excessive warfarin therapy, which she took prophylactically due to deep vein thrombosis, was seen in the psychiatry clinic for depression. She had a history of substance abuse and binge drinking. However, she reported that she had stopped drinking and had remained abstinent for the past year because of fear of further damaging her kidneys. Laboratory tests showed AST of 13 U/L, ALT of 19 U/L, but an elevated GGT level of 104 U/L. Her MCV was also elevated to 101 fL. The combined elevated GGT and MCV has a sensitivity of 95% for alcohol abuse, and her laboratory tests indicated that she had recently consumed a substantial amount of alcohol [69].

Professional Resources

The Alcohol Use Disorders Identification Test (Bush et al., 1998)

4.13.2.2.3 Alcohol Use Disorders Identification Test

The Alcohol Use Disorder Identification Test (Saunders et al., 1993) consists of ten items measuring different aspects of problematic alcohol use, including frequency of alcohol use, number of alcoholic drinks consumed in a typical day, consumption of 6 or more drinks in one sitting, inability to stop drinking, failure to complete everyday tasks, consuming an alcoholic beverage upon waking, guilt after drinking, inability to recall events while drinking, frequency of injuries due to consuming alcohol, or occurrence of discussion related to drinking less (Saunders et al., 1993). Items are summed together, with a score of 15 or greater indicating likely alcohol dependence or moderate alcohol use disorder. Last, due to the co-occurrence of problematic alcohol and drug use, the DAST-10 is frequently administered with the Alcohol Use Disorder Identification Test (SBIRT; Babor et al., 2007).

Commonly used screening questionnaires

List of Abbreviations

Aβ

amyloid beta

anterior cingulate cortex

alcohol use disorders identification test

blood–brain barrier

body mass index

brief visual memory test–Revised

continuous positive airway pressure

C-reactive protein

California verbal learning test–2nd Edition

California verbal learning test–2nd Edition–Short Form

free fatty acids

insulin resistance

longitudinal assessment of Bariatric surgery

Minnesota multiphasic personality inventory–2nd Edition–Restructured Form

mild cognitive impairment

obstructive sleep apnea

prefrontal cortex

Questionnaire on eating and weight patterns–Revised

tumor necrosis factor

Wechsler Abbreviated scale of intelligence–2nd Edition

Wechsler adult intelligence scale–4th Edition

Wechsler memory scale–4th Edition

Wide range achievement test–4th Edition

Accuracy of Screening

Several effective screening instruments are available for use in the primary care setting. The Alcohol Use Disorders Identification Test (AUDIT) incorporates questions about consequences of drinking along with questions about quantity and frequency. Its specificity ranges from 78% to 96% and the sensitivity from 51% to 97%. The CAGE questionnaire (i.e., feeling the need to cut down, annoyed by criticism, guilty about drinking, and need for an eye-opener in the morning) is widely used in primary care. Specificity for CAGE ranges from 70% to 97% and sensitivity from 43% to 94%. The TWEAK and the T-ACE instruments are designed to screen pregnant women for alcohol misuse (Whitlock et al., 2004). The CRAFFT questionnaire has been validated for screening adolescents for substance abuse in primary care settings (Knight et al., 2003). Tools are available at http://www.niaaa.nih.gov/Publications/AlcoholResearch/. Biologic markers, such as carbohydrate-deficient transferring and serum γ-glutamyltransferase, are poor indicators of alcohol misuse.

Screening and Assessment

Key Points

Apply CAGE screening to all patients older than 18.

Be aware of “negative” drinking history.

Closely follow up positive responses.

The AUDIT-C is a standard for quantifying alcohol use disorders in medical settings.

There is good evidence to support screening for alcohol dependency and alcohol use disorders when using standard screening tools in practice. For the family physician, the diagnosis of alcoholism often depends on clues from the history and physical examination (Box 49-1). Possible clues may include a history of driving under the influence (DUI) or an MVC; history of repetitive trauma; new-onset hypertension, gastritis, or pancreatitis; other, otherwise unexplained liver disease (AST > ALT); presence of depression; recent loss of employment or separation from family; unexplained tremor; upper gastrointestinal (GI) bleeding; recent falls or accidents; and a history of family or marital violence.

The four CAGE questions (cut down, annoyed, guilty, eye opener) are adequate for screening purposes (Box 49-2), derived from the longer Michigan Alcoholism Screening Test (MAST) questions (see eTable 49-1 online) (Hays and Spickard, 1987; Powers and Spikard, 1984). Two positive responses are considered a positive screen and indicate that further assessment is warranted. An important point is that family physicians should not assume that someone does not have an alcohol use disorder when that person answers negatively to questions about drinking. If such patients do not use alcohol at all, it may indicate that they had to quit because they had problems with alcohol. Given the prevalence of alcohol use disorders, it is recommended that the CAGE questions be applied to all patients older than 18 years. Another brief set of screening questions is the TWEAK questionnaire: tolerance, worries, eye openers, amnesia, and cut down (Box 49-3).

Longer screening questionnaires include the MAST and the Alcohol Use Disorders Test (AUDIT: see eTable 49-2 online) (Saunders et al., 1993). Both are considered higher in predictive value but more difficult to administer. Age-specific and population-specific survey tools are also available, including the Geriatric Alcoholism Screen and an adolescent alcoholism inventory. The 10-item Core questionnaire includes three questions on alcohol consumption (the AUDIT-C) and seven on the impact of alcohol use. The AUDIT has been shown to have good sensitivity and specificity in medical and general populations and has recently been useful for screening patients with major psychiatric disorders and as an assessment instrument for patients seeking treatment for alcohol use disorders (Cassidy et al., 2008; Donovan et al., 2006). The AUDIT-C provides an efficient standardized method for assessing the quantity and frequency of alcohol use and accounts for much of the test’s discriminative power in medical populations (Rodriguez-Marros and Santamarina, 2007).

Alcohol Screening

Several brief screening instruments can be used in primary care and other health settings to identify patients who may have AUDs (or are at risk for AUD development) and thus may benefit from further intervention. These include the Alcohol Use Disorders Identification Test (AUDIT), the CAGE questionnaire, and the Michigan Alcoholism Screening Test (MAST). These instruments appear more effective at identifying problem drinkers than informal screening methods. However, there are questions about the value and feasibility of global screening efforts, given the time required and the low payoff (e.g., infrequent identification of problem drinkers, with even fewer heeding treatment referrals).