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Screening

High-risk alcohol use and AUD are widespread issues. Alcohol is linked to more than 200 diseases and injuries, such as cancer, heart disease, liver disease, violence and car accidents.

In Canada:

  • 18% of people > 15 years met the clinical criteria for AUD during their lifetime.
  • 57% of people > 15 years currently drink more than 2 drinks/week, which is defined as “above low-risk” for negative health consequences in Canada’s Guidance on Alcohol and Health (2023).

 

Primary care providers play a vital role in identifying and treating high-risk drinking and AUD. You can also help patients and families connect with specialized services and supportive resources in their communities.

 

When patients live in rural or under-resourced communities with limited access to health care resources, your role becomes even more critical as you may be one of only a few primary care providers available to provide screening, diagnosis, care planning and treatment.

Research has not clearly shown an optimal frequency for screening, but screening on a regular basis is recommended to detect alcohol problems early on. The Guideline committee suggests screening once a year can be feasible and practical.

Tips to start the conversation

Some patients may be hesitant to discuss their drinking with you. In particular, individuals who belong to underserved populations—such as Indigenous people and other people of colour, youth and those who identify as 2SLGBTQ+—may have had prior negative experiences with health care providers which left them feeling guarded and less likely to answer questions openly.

 

Here are some tips to initiate the conversation about alcohol with your patient and help them feel comfortable:

 

  • Seek consent before asking the patient about their drinking.
  • Let the patient know that what they share with you is confidential.
  • Use a non-judgmental and conversational tone to start the conversation.
    Ask open-ended questions.
  • Understand that gaining the patient’s trust may take more than a single visit.

Sample dialogue

 

“I talk to all my patients about alcohol and other substance use. Would it be alright for us to talk about this now?”

 

If yes:

“How does alcohol fit in your life?”

“What kind of relationship do you have with alcohol?”

“Do you sometimes drink wine, beer or other alcoholic beverages?”

The Public Health Agency of Canada has published a useful resource for Canadian health professionals titled Communicating About Substance Use in Compassionate, Safe and Non-Stigmatizing Ways (2020). This resource was developed through consultation with people with lived and living experience of substance use and their loved ones, health professional organizations, and other stakeholders in the Canadian health system.

download resource

Continuum of alcohol-related risks

Canada’s Guidance on Alcohol and Health: Final Report summarizes evidence drawn from worldwide evidence reviews, mathematical modelling, and extensive consultations and discussions, and provides information about the risks of harm associated with alcohol consumption. Based on that evidence, the report recommends that Canadians consume no more than 1-2 standard drinks per week if they want to stay within the “low-risk” category.
 

The continuum of alcohol-related risks included in the report is based on the risks of developing different alcohol-related health problems, such as cancer, heart disease, stroke, liver disease, high blood pressure and accidental injuries.
 

Talking to your patient about these risks can help guide conversations toward alcohol use screening and provide some education at the same time.

Sample dialogue

 

“Canada has guidance about drinking and its impacts on health. Would you be interested in hearing their recommendations? I try to inform all my patients on how to prevent health issues related to alcohol.”

Canada’s Guidance on Alcohol and Health: Continuum of Alcohol-related Risks

 

 

download table

Click on the button to download Canada’s Guidance on Alcohol and Health: Final Report.

 

download

Defining a standard drink

When you talk to your patient about alcohol use, they may ask you how you define a standard drink. This graphic can be useful, as it shows visual representations of a standard drink based on different types of alcohol.

What Is a Standard Drink?

Screening tools

Before you start the screening, make sure you seek consent from the patient and check their comfort level. This is especially important if the patient appears to be guarded or reluctant to talk, or if they may belong to an underserved population and may have had prior negative experiences with the health care system.

Sample dialogue

 

“I like to talk to all my patients about alcohol and other substance use so that I can understand how best to care for them. Are you comfortable talking about this today?”

Single Alcohol Screening Question (SASQ)

 

“In the past year, how often have you had more than 4 drinks (women) or 5 drinks (men) on any one occasion?”

 

  • Screens for high-risk alcohol use in adults.
  • High sensitivity and specificity.
  • If response is 1 or more times, the screen is positive.
  • Follow up with another screening tool, such as AUDIT, AUDIT-C or CAGE.

Full screening tools – recommended for adults or youth

Alcohol Use Disorders Identification Test – Consumption (AUDIT-C)

calculator

  • 3 questions
  • Well-validated in many settings and patient populations
  • Standard drink size = 10g ethanol (different from Canada’s Guidance on Alcohol and Health which says 13.45g)

 

Scoring

 

0 to 4 = Low risk

 

5 to 7 = Moderate risk

→ Provide brief advice

 

≥ 8 = High risk

→ Proceed to diagnosis

Alcohol Use Disorders Identification Test (AUDIT)

calculator

  • 10 questions
  • Well-validated in many settings and patient populations, but less specific for identifying women
  • Standard drink size = 10g ethanol (different from Canada’s Guidance on Alcohol and Health which says 13.45g)

Scoring

 

*Note: Originally designed to screen for hazardous and harmful alcohol use, to align with ICD-10 codes. For clinical decision-making, scores and interpretation below have been categorized into low-, moderate- and high-risk for AUD.

 

0 to 7 = Low risk

 

8 to 15 = Moderate risk

→ Provide brief advice

 

≥ 16 = High risk

→ Proceed to diagnosis

The Cut-down, Annoyed, Guilty, Eye Opener (CAGE) Tool

calculator

  • 4 items
  • Validated for primary care
  • More sensitive for moderate to severe AUD than mild AUD or high-risk drinking

 

Scoring

≥ 2 = potential for AUD

→ Proceed to diagnosis

 

Screening tools specifically for youth

National Institute on Alcohol Abuse and Alcoholism (NIAAA) Youth Screening Tool (Ages 11-18)

  1. “Do you have any friends who drank beer, wine or another type of alcohol in the past year?”
  2. “How about you—in the past year, on how many days have you had more than a few sips of beer, wine or another type of alcohol?”
  • 2 questions
  • Validated for ages 11–18
  • Identifies risk for current or future AUD
  • Detailed information available in the NIAAA Guide

Scoring for question # 2

 

Age High-risk threshold for past year drinking
11 years 1 day
12–15 years 6 days
16 years 12 days
17 years 24 days
18 years 52 days

 

→ Proceed to diagnosis, brief intervention and treatment planning
OR
→ Brief intervention and referral to a
youth addictions specialist

Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) Tool (Ages 12–21)

PART 1: Ask: “In the past year, on how many days have you had more than a few sips of beer, wine or another type of alcohol?”

 

If the answer is 1 or more, proceed to:
PART 2: https://www.thecalculator.co/health/CRAFFT-Screening-Test-973.html

  • 6 questions
  • Validated for ages 12–21
  • Validated in diverse populations
  • Identifies any substance use disorder
  • Has high sensitivity and specificity for AUD

Scoring

 

≥ 2 “Yes” answers = High risk

→ Proceed to diagnosis, brief intervention and treatment planning
OR
→ Brief intervention and referral to a
youth addictions specialist

Screening tools for older adults (65 and older)

Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G)

calculator

  • 10 questions
  • Designed for older adults
  • Allows for further discussion of symptoms and reasons for drinking

 

Scoring

 

≥ 2 “ Yes” answers = High risk

→ Proceed to diagnosis

 

The Cut-down, Annoyed, Guilty, Eye Opener (CAGE) Tool

calculator

  • 4 items
  • Performs equally to the SMAST-G and is shorter
  • More sensitive for moderate to severe AUD than mild AUD or high-risk drinking

Scoring

 

≥ 2 = Potential for AUD

→ Proceed to diagnosis