Keji Fagbemi, MD

Substance use disorder and its daily consequences take no breaks even during a pandemic. The stressors created by COVID-19, including deaths of loved ones and the disruptions to normal life from policies aimed at flattening the curve, seem to have increased substance use.

Courtesy Dr. Keji Fagbemi

I practice as a hospitalist with an internal medicine background and specialty in addiction medicine at BronxCare Health System’s inpatient detoxification unit, a 24/7, 20-bed medically-supervised unit in South Bronx in New York City. It is one of the comprehensive services provided by the BronxCare’s life recovery center and addiction services, which also includes an outpatient clinic, opioid treatment program, inpatient rehab, and a half-way house. Inpatient detoxification units like ours are designed to treat serious addictions and chemical dependency and prevent and treat life-threatening withdrawal symptoms and signs or complications. Our patients come from all over the city and its adjoining suburbs, including from emergency room referrals, referral clinics, courts and the justice system, walk-ins, and self-referrals.

At a time when many inpatient detoxification units within the city were temporarily closed due to fear of inpatient spread of the virus or to provide extra COVID beds in anticipation for the peak surge, we have been able to provide a needed service. In fact, several other inpatient detoxification programs within the city have been able to refer their patients to our facility.

Individuals with substance use disorder have historically been a vulnerable and underserved population and possess high risk for multiple health problems as well as preexisting conditions. Many have limited life options financially, educationally, and with housing, and encounter barriers to accessing primary health care services, including preventive services. The introduction of the COVID-19 pandemic into these patients’ precarious health situations only made things worse as many of the limited resources for patients with substance use disorder were diverted to battling the pandemic. Numerous inpatient and outpatient addiction services, for example, were temporarily shut down. This has led to an increase in domestic violence, and psychiatric decompensation, including psychosis, suicidal attempts, and worsening of medical comorbidities in these patients.

Our wake-up call came when the first case of COVID-19 was confirmed in New York in early March. Within a short period of time the state became the epicenter for COVID-19. With the projection of millions of cases being positive and the number of new cases doubling every third day at the onset in New York City, we knew we had a battle brewing and needed to radically transform our mode of operation fast.

Our first task was to ensure the safety of our patients and the dedicated health workers attending to them. Instead of shutting down we decided to focus on education, screening, mask usage, social distancing, and intensifying hygiene. We streamlined the patient point of entry through one screening site, while also brushing up on our history-taking to intently screen for COVID-19. This included not just focusing on travels from China, but from Europe and other parts of the world.

Yes, we did ask patients about cough, fever, shortness of breath or difficulty breathing, feeling fatigued, severe body ache, and possible contact with someone who is sick or has traveled overseas. But we were also attuned to the increased rate of community spread and the presentation of other symptoms, such as loss of taste and smell, early in the process. Hence we were able to triage patients with suspected cases to the appropriate sections of the hospital for further screening, testing, and evaluation, instead of having those patients admitted to the detox unit.

 

Early in the process a huddle team was instituted with daily briefing of staff lasting 30 minutes or less. This team consists of physicians, nurses, a physician assistant, a social worker, and a counselor. In addition to discussing treatment plans for the patient, they deliberate on the public health information from the hospital’s COVID-19 command center, New York State Department of Health, the Office of Mental Health, and the Centers for Disease Control and Prevention concerning the latest evidence-based information. These discussions have helped us modify our policies and practices.

We instituted a no visiting rule during a short hospital stay of 5-7 days, and this was initiated weeks in advance of many institutions, including nursing homes with vulnerable populations. Our admitting criteria was reviewed to allow for admission of only those patients who absolutely needed inpatient substance use disorder treatment, including patients with severe withdrawal symptoms and signs, comorbidities, or neuropsychiatric manifestations that made them unsafe for outpatient or home detoxification. Others were triaged to the outpatient services which was amply supported with telemedicine. Rooms and designated areas of the building were earmarked as places for isolation/quarantine if suspected COVID-19 cases were identified pending testing. To assess patients’ risk of COVID-19, we do point-of-care nasopharyngeal swab testing with polymerase chain reaction.

Regarding face masks, patients and staff were fitted with ones early in the process. Additionally, staff were trained on the importance of face mask use and how to ensure you have a tight seal around the mouth and nose and were provided with other appropriate personal protective equipment. Concerning social distancing, we reduced the patient population capacity for the unit down to 50% and offered only single room admissions. Social distancing was encouraged in the unit, including in the television and recreation room and dining room, and during small treatment groups of less than six individuals. Daily temperature checks with noncontact handheld thermometers were enforced for staff and anyone coming into the life recovery center.

Patients are continuously being educated on the presentations of COVID-19 and encouraged to report any symptoms. Any staff feeling sick or having symptoms are encouraged to stay home. Rigorous and continuous cleaning of surfaces, especially of areas subjected to common use, is done frequently by the hospital housekeeping and environmental crew and is the order of the day.

Courtesy Dr. Keji Fagbemi

Even though we seem to have passed the peak of the pandemic curve for the city, we know that we are not out of the woods yet. We feel confident that our experience has made us better prepared going forward. The changes we have implemented have become part and parcel of daily caring for our patient population. We believe they are here to stay for a while, or at least until the pandemic is curtailed as we strive toward getting an effective vaccine.

Dr. Fagbemi is a hospitalist at BronxCare Health System, a not-for-profit health and teaching hospital system serving South and Central Bronx in New York. He has no conflicts of interest to disclose.

Substance use disorder and its daily consequences take no breaks even during a pandemic. The stressors created by COVID-19, including deaths of loved ones and the disruptions to normal life from policies aimed at flattening the curve, seem to have increased substance use.

Courtesy Dr. Keji Fagbemi

I practice as a hospitalist with an internal medicine background and specialty in addiction medicine at BronxCare Health System’s inpatient detoxification unit, a 24/7, 20-bed medically-supervised unit in South Bronx in New York City. It is one of the comprehensive services provided by the BronxCare’s life recovery center and addiction services, which also includes an outpatient clinic, opioid treatment program, inpatient rehab, and a half-way house. Inpatient detoxification units like ours are designed to treat serious addictions and chemical dependency and prevent and treat life-threatening withdrawal symptoms and signs or complications. Our patients come from all over the city and its adjoining suburbs, including from emergency room referrals, referral clinics, courts and the justice system, walk-ins, and self-referrals.

At a time when many inpatient detoxification units within the city were temporarily closed due to fear of inpatient spread of the virus or to provide extra COVID beds in anticipation for the peak surge, we have been able to provide a needed service. In fact, several other inpatient detoxification programs within the city have been able to refer their patients to our facility.

Individuals with substance use disorder have historically been a vulnerable and underserved population and possess high risk for multiple health problems as well as preexisting conditions. Many have limited life options financially, educationally, and with housing, and encounter barriers to accessing primary health care services, including preventive services. The introduction of the COVID-19 pandemic into these patients’ precarious health situations only made things worse as many of the limited resources for patients with substance use disorder were diverted to battling the pandemic. Numerous inpatient and outpatient addiction services, for example, were temporarily shut down. This has led to an increase in domestic violence, and psychiatric decompensation, including psychosis, suicidal attempts, and worsening of medical comorbidities in these patients.

Our wake-up call came when the first case of COVID-19 was confirmed in New York in early March. Within a short period of time the state became the epicenter for COVID-19. With the projection of millions of cases being positive and the number of new cases doubling every third day at the onset in New York City, we knew we had a battle brewing and needed to radically transform our mode of operation fast.

Our first task was to ensure the safety of our patients and the dedicated health workers attending to them. Instead of shutting down we decided to focus on education, screening, mask usage, social distancing, and intensifying hygiene. We streamlined the patient point of entry through one screening site, while also brushing up on our history-taking to intently screen for COVID-19. This included not just focusing on travels from China, but from Europe and other parts of the world.

Yes, we did ask patients about cough, fever, shortness of breath or difficulty breathing, feeling fatigued, severe body ache, and possible contact with someone who is sick or has traveled overseas. But we were also attuned to the increased rate of community spread and the presentation of other symptoms, such as loss of taste and smell, early in the process. Hence we were able to triage patients with suspected cases to the appropriate sections of the hospital for further screening, testing, and evaluation, instead of having those patients admitted to the detox unit.

 

Early in the process a huddle team was instituted with daily briefing of staff lasting 30 minutes or less. This team consists of physicians, nurses, a physician assistant, a social worker, and a counselor. In addition to discussing treatment plans for the patient, they deliberate on the public health information from the hospital’s COVID-19 command center, New York State Department of Health, the Office of Mental Health, and the Centers for Disease Control and Prevention concerning the latest evidence-based information. These discussions have helped us modify our policies and practices.

We instituted a no visiting rule during a short hospital stay of 5-7 days, and this was initiated weeks in advance of many institutions, including nursing homes with vulnerable populations. Our admitting criteria was reviewed to allow for admission of only those patients who absolutely needed inpatient substance use disorder treatment, including patients with severe withdrawal symptoms and signs, comorbidities, or neuropsychiatric manifestations that made them unsafe for outpatient or home detoxification. Others were triaged to the outpatient services which was amply supported with telemedicine. Rooms and designated areas of the building were earmarked as places for isolation/quarantine if suspected COVID-19 cases were identified pending testing. To assess patients’ risk of COVID-19, we do point-of-care nasopharyngeal swab testing with polymerase chain reaction.

Regarding face masks, patients and staff were fitted with ones early in the process. Additionally, staff were trained on the importance of face mask use and how to ensure you have a tight seal around the mouth and nose and were provided with other appropriate personal protective equipment. Concerning social distancing, we reduced the patient population capacity for the unit down to 50% and offered only single room admissions. Social distancing was encouraged in the unit, including in the television and recreation room and dining room, and during small treatment groups of less than six individuals. Daily temperature checks with noncontact handheld thermometers were enforced for staff and anyone coming into the life recovery center.

Patients are continuously being educated on the presentations of COVID-19 and encouraged to report any symptoms. Any staff feeling sick or having symptoms are encouraged to stay home. Rigorous and continuous cleaning of surfaces, especially of areas subjected to common use, is done frequently by the hospital housekeeping and environmental crew and is the order of the day.

Courtesy Dr. Keji Fagbemi

Even though we seem to have passed the peak of the pandemic curve for the city, we know that we are not out of the woods yet. We feel confident that our experience has made us better prepared going forward. The changes we have implemented have become part and parcel of daily caring for our patient population. We believe they are here to stay for a while, or at least until the pandemic is curtailed as we strive toward getting an effective vaccine.

Dr. Fagbemi is a hospitalist at BronxCare Health System, a not-for-profit health and teaching hospital system serving South and Central Bronx in New York. He has no conflicts of interest to disclose.

Substance use disorder and its daily consequences take no breaks even during a pandemic. The stressors created by COVID-19, including deaths of loved ones and the disruptions to normal life from policies aimed at flattening the curve, seem to have increased substance use.

Courtesy Dr. Keji Fagbemi

I practice as a hospitalist with an internal medicine background and specialty in addiction medicine at BronxCare Health System’s inpatient detoxification unit, a 24/7, 20-bed medically-supervised unit in South Bronx in New York City. It is one of the comprehensive services provided by the BronxCare’s life recovery center and addiction services, which also includes an outpatient clinic, opioid treatment program, inpatient rehab, and a half-way house. Inpatient detoxification units like ours are designed to treat serious addictions and chemical dependency and prevent and treat life-threatening withdrawal symptoms and signs or complications. Our patients come from all over the city and its adjoining suburbs, including from emergency room referrals, referral clinics, courts and the justice system, walk-ins, and self-referrals.

At a time when many inpatient detoxification units within the city were temporarily closed due to fear of inpatient spread of the virus or to provide extra COVID beds in anticipation for the peak surge, we have been able to provide a needed service. In fact, several other inpatient detoxification programs within the city have been able to refer their patients to our facility.

Individuals with substance use disorder have historically been a vulnerable and underserved population and possess high risk for multiple health problems as well as preexisting conditions. Many have limited life options financially, educationally, and with housing, and encounter barriers to accessing primary health care services, including preventive services. The introduction of the COVID-19 pandemic into these patients’ precarious health situations only made things worse as many of the limited resources for patients with substance use disorder were diverted to battling the pandemic. Numerous inpatient and outpatient addiction services, for example, were temporarily shut down. This has led to an increase in domestic violence, and psychiatric decompensation, including psychosis, suicidal attempts, and worsening of medical comorbidities in these patients.

Our wake-up call came when the first case of COVID-19 was confirmed in New York in early March. Within a short period of time the state became the epicenter for COVID-19. With the projection of millions of cases being positive and the number of new cases doubling every third day at the onset in New York City, we knew we had a battle brewing and needed to radically transform our mode of operation fast.

Our first task was to ensure the safety of our patients and the dedicated health workers attending to them. Instead of shutting down we decided to focus on education, screening, mask usage, social distancing, and intensifying hygiene. We streamlined the patient point of entry through one screening site, while also brushing up on our history-taking to intently screen for COVID-19. This included not just focusing on travels from China, but from Europe and other parts of the world.

Yes, we did ask patients about cough, fever, shortness of breath or difficulty breathing, feeling fatigued, severe body ache, and possible contact with someone who is sick or has traveled overseas. But we were also attuned to the increased rate of community spread and the presentation of other symptoms, such as loss of taste and smell, early in the process. Hence we were able to triage patients with suspected cases to the appropriate sections of the hospital for further screening, testing, and evaluation, instead of having those patients admitted to the detox unit.

 

Early in the process a huddle team was instituted with daily briefing of staff lasting 30 minutes or less. This team consists of physicians, nurses, a physician assistant, a social worker, and a counselor. In addition to discussing treatment plans for the patient, they deliberate on the public health information from the hospital’s COVID-19 command center, New York State Department of Health, the Office of Mental Health, and the Centers for Disease Control and Prevention concerning the latest evidence-based information. These discussions have helped us modify our policies and practices.

We instituted a no visiting rule during a short hospital stay of 5-7 days, and this was initiated weeks in advance of many institutions, including nursing homes with vulnerable populations. Our admitting criteria was reviewed to allow for admission of only those patients who absolutely needed inpatient substance use disorder treatment, including patients with severe withdrawal symptoms and signs, comorbidities, or neuropsychiatric manifestations that made them unsafe for outpatient or home detoxification. Others were triaged to the outpatient services which was amply supported with telemedicine. Rooms and designated areas of the building were earmarked as places for isolation/quarantine if suspected COVID-19 cases were identified pending testing. To assess patients’ risk of COVID-19, we do point-of-care nasopharyngeal swab testing with polymerase chain reaction.

Regarding face masks, patients and staff were fitted with ones early in the process. Additionally, staff were trained on the importance of face mask use and how to ensure you have a tight seal around the mouth and nose and were provided with other appropriate personal protective equipment. Concerning social distancing, we reduced the patient population capacity for the unit down to 50% and offered only single room admissions. Social distancing was encouraged in the unit, including in the television and recreation room and dining room, and during small treatment groups of less than six individuals. Daily temperature checks with noncontact handheld thermometers were enforced for staff and anyone coming into the life recovery center.

Patients are continuously being educated on the presentations of COVID-19 and encouraged to report any symptoms. Any staff feeling sick or having symptoms are encouraged to stay home. Rigorous and continuous cleaning of surfaces, especially of areas subjected to common use, is done frequently by the hospital housekeeping and environmental crew and is the order of the day.

Courtesy Dr. Keji Fagbemi

Even though we seem to have passed the peak of the pandemic curve for the city, we know that we are not out of the woods yet. We feel confident that our experience has made us better prepared going forward. The changes we have implemented have become part and parcel of daily caring for our patient population. We believe they are here to stay for a while, or at least until the pandemic is curtailed as we strive toward getting an effective vaccine.

Dr. Fagbemi is a hospitalist at BronxCare Health System, a not-for-profit health and teaching hospital system serving South and Central Bronx in New York. He has no conflicts of interest to disclose.

Popular questionnaires to screen for alcohol misuse include the CAGE, the TWEAK, and the short form of the Alcohol Use Disorder Identification Test (AUDIT-C). Any of these is recommended. The important thing is to be proactive about screening for this very common and underrecognized problem.

A COMMON PROBLEM, NOT OFTEN ADMITTED

Alcohol use disorder, which ranges from hazardous drinking to binge drinking and alcohol dependence, is more common than admitted and often goes undiagnosed. Its personal, societal, and economic consequences cannot be overemphasized. Alcohol use is responsible for 85,000 deaths each year in the United States, and it is linked to substantial medical and psychiatric consequences and injuries, especially motor vehicle accidents. The estimated annual cost of problems attributed to alcohol use is over $185 billion.¹

About three in 10 US adults drink at levels that increase their risk for alcohol-related consequences, and about one in four adults currently abuses alcohol or is dependent on it.² In 2009, 6.8% of the US population age 12 and above reported heavy drinking, with highest rates in those ages 21 to 29.³ The rate of alcohol use was higher in men than in women, but about 10% of pregnant women ages 15 to 44 reported current alcohol use.³

The prevalence of alcohol use disorder ranges from 2% to 29% in a typical ambulatory primary care medical practice.⁴ And only one-third of people with alcohol use disorder are diagnosed.

Studies and experience have shown that problem drinkers tend to not seek help until they have advanced dependence, often with associated medical and sociolegal complications. It is also well established that the earlier the diagnosis is made and appropriate intervention is offered, the better the prognosis.

WHAT IS THE GOAL OF SCREENING?

The goals of screening for alcohol use disorder are to estimate the patient’s risk level, to identify those at risk because they exceed defined limits, and to identify those with evidence of an active problem, ie, with adverse consequences related to their drinking. This screening paves the way for further assessment, definitive diagnosis, and a treatment plan.

The US Preventive Services Task Force recommends screening and behavioral counseling interventions (such as a brief intervention) in the primary care setting to reduce alcohol misuse by adults, including pregnant women.⁵ In addition, most primary care patients who screen positive for heavy drinking or alcohol use disorder show motivation and readiness to change, and those with the most severe symptoms tend to be the most ready.⁶

THE IDEAL QUESTIONNAIRE: SENSITIVE, SPECIFIC, AND SHORT

The ideal alcohol screening questionnaire for a busy practice should be brief and highly sensitive and specific for identifying the spectrum of alcohol misuse. Also, it should be easy to recall so it can be part of routine face-to-face discussion with the patient during an office visit.

Further, it should include questions that focus on the consequences of drinking as well as on quantity and frequency. It should also take into account factors such as the patient’s age, sex, race or ethnicity, and pregnancy status, as these can influence the effectiveness of the screening method.

Problems with focusing on quantity alone

“Risky use” is defined (in a non-alcohol-dependent person or one with no alcohol-related consequences) as more than seven standard drinks per week or more than three per occasion for women, and more than 14 standard drinks per week or more than four per occasion for men.²

A standard drink in the United States contains about 12 to 14 g of ethanol: a 12-oz can or bottle of beer, a 5-oz glass of wine, or about 1.5 oz of 80-proof liquor.²

The common single-item screening test asks, “How many times in the past year have you had more than four drinks (for women) or five drinks (for men) in a day?” This is recommended by the National Institute on Alcohol Abuse and Alcoholism for brief screening in primary care. However, a positive answer (ie, one or more times in the past year) has a sensitivity of only 82% and a specificity of only 79% for detecting unhealthy alcohol use, and an even lower specificity (67%) for detecting current alcohol use disorder.⁷

The CAGE questionnaire

The four-item CAGE questionnaire⁸ focuses on the consequences of drinking:

• C: Have you felt the need to cut down on your drinking?
• A: Have you ever felt annoyed by someone criticizing your drinking?
• G: Have you ever felt bad or guilty about your drinking?
• E: Have you ever had an eye-opener—a drink the first thing in the morning to steady your nerves?

A yes to one or more of the questions denotes a need for further assessment.

The CAGE questionnaire is simple, non-threatening, brief, and easy to remember. A yes answer to two or more items has a sensitivity of 75% to 95% and a specificity of 84% to 97% for alcohol dependence.⁹ However, CAGE is less sensitive for identifying nonalcohol-dependent at-risk drinkers. The patient’s sex and ethnicity have also been found to affect its performance somewhat, with some studies showing a sensitivity as low as 50% in adult white women and as low as 40% in at-risk groups ages 60 and over.

 

 

The TWEAK questionnaire

The TWEAK is a modification of the CAGE and includes a question about tolerance; it has a sensitivity of 87% for harmful drinking and 84% for dependence, especially in trauma-related cases.⁹ It has also been found to be better than the CAGE for screening pregnant patients.

• Tolerance: How many drinks can you hold without falling asleep or passing out? (2 points if six drinks or more)
• Worried: Have friends or relatives worried about your drinking? (2 points if yes)
• Eye-opener: Do you sometimes take a drink in the morning when you first get up? (1 point if yes)
• Amnesia: Have friends or relatives told you about things you said or did while drinking that you could not remember? (1 point if yes)
• Cut down: Do you sometimes feel the need to cut down on your drinking? (1 point if yes)

An answer of ≥ 6 to the first question or a total score of 3 or more denotes a problem with alcohol use and a need for further assessment.¹⁰

The AUDIT-C

The AUDIT-C, a shorter form of the 10-item AUDIT developed by the World Health Organization, uses only the first three questions of the full-length AUDIT. The three-item AUDIT-C has a sensitivity ranging from 85% in Hispanic women to 95% in white men.^9,11 The questions center on the quantity and frequency of alcohol use:

• How often do you have a drink containing alcohol? Answer choices: never; monthly or less often; 2 to 4 times a month; 2 to 3 times a week; 4 or more times a week.
• How many standard drinks containing alcohol do you have on a typical day when you are drinking? Answer choices: one or two; three or four; five or six; seven to nine; 10 or more.
• How often do you have six or more drinks on one occasion? Answer choices: never, less than monthly; monthly; weekly; daily or almost.

Scoring is 0 for never, and 1, 2, 3, or 4 for the subsequent answer choices in each question.

The cut-off score for the AUDIT-C is usually a total of 3 points for women and 4 for men: ie, a score of 3 or higher for women and a score of 4 or higher for men indicate alcohol use disorder and the need for further assessment.

The AUDIT questionnaire has been found not only to have a high sensitivity (83%) and specificity (90%) for identifying alcohol dependence, but also to be more sensitive than the CAGE questionnaire (85% vs 75%) for identifying harmful drinking, hazardous drinking, and at-risk drinking. (Note: The full version of AUDIT performed similarly to the three-item AUDIT-C for detecting heavy drinking and active abuse or dependence.¹²) Furthermore, it has performed well as a screening test in many multinational trials of alcohol brief intervention. The questions about quantity of alcohol consumed may be even more suitable for adolescents and young adults, who tend to fall into the harmful-hazardous drinking category rather than the dependent category. In some studies, patients tended to reveal less with the CAGE questionnaire when it was preceded by direct and close-ended questions about the quantity and frequency of alcohol use, thus reducing its sensitivity.¹³

The AUDIT and TWEAK questionnaires showed greater sensitivity in both men and women than the CAGE questionnaire and were equally sensitive in African Americans.¹⁴

HOW TO FIT ALCOHOL SCREENING INTO AN OFFICE VISIT

A practical way to fit alcohol screening into an office visit is to include a questionnaire in the assessment papers completed by the patient while in the waiting room. In other settings, these questions may be asked by trained nursing staff as part of the initial assessment, ie, while obtaining the patient’s weight and vital statistics. This can be briefly reviewed by the physician during the face-to-face history and physical examination.

A concerted effort is needed to proactively screen for alcohol use. A combination of questions about the effect, the quantity, and the frequency of alcohol use is the best way to screen for the many different aspects of alcohol use disorder—many of which can be managed in the primary care setting through brief interventions without referral to a specialist.

When screening for alcohol misuse, it is also important to consider factors such as age, sex, race or ethnicity, pregnancy, and history of recent trauma or surgery.

Popular questionnaires to screen for alcohol misuse include the CAGE, the TWEAK, and the short form of the Alcohol Use Disorder Identification Test (AUDIT-C). Any of these is recommended. The important thing is to be proactive about screening for this very common and underrecognized problem.

A COMMON PROBLEM, NOT OFTEN ADMITTED

Alcohol use disorder, which ranges from hazardous drinking to binge drinking and alcohol dependence, is more common than admitted and often goes undiagnosed. Its personal, societal, and economic consequences cannot be overemphasized. Alcohol use is responsible for 85,000 deaths each year in the United States, and it is linked to substantial medical and psychiatric consequences and injuries, especially motor vehicle accidents. The estimated annual cost of problems attributed to alcohol use is over $185 billion.¹

About three in 10 US adults drink at levels that increase their risk for alcohol-related consequences, and about one in four adults currently abuses alcohol or is dependent on it.² In 2009, 6.8% of the US population age 12 and above reported heavy drinking, with highest rates in those ages 21 to 29.³ The rate of alcohol use was higher in men than in women, but about 10% of pregnant women ages 15 to 44 reported current alcohol use.³

The prevalence of alcohol use disorder ranges from 2% to 29% in a typical ambulatory primary care medical practice.⁴ And only one-third of people with alcohol use disorder are diagnosed.

Studies and experience have shown that problem drinkers tend to not seek help until they have advanced dependence, often with associated medical and sociolegal complications. It is also well established that the earlier the diagnosis is made and appropriate intervention is offered, the better the prognosis.

WHAT IS THE GOAL OF SCREENING?

The goals of screening for alcohol use disorder are to estimate the patient’s risk level, to identify those at risk because they exceed defined limits, and to identify those with evidence of an active problem, ie, with adverse consequences related to their drinking. This screening paves the way for further assessment, definitive diagnosis, and a treatment plan.

The US Preventive Services Task Force recommends screening and behavioral counseling interventions (such as a brief intervention) in the primary care setting to reduce alcohol misuse by adults, including pregnant women.⁵ In addition, most primary care patients who screen positive for heavy drinking or alcohol use disorder show motivation and readiness to change, and those with the most severe symptoms tend to be the most ready.⁶

THE IDEAL QUESTIONNAIRE: SENSITIVE, SPECIFIC, AND SHORT

The ideal alcohol screening questionnaire for a busy practice should be brief and highly sensitive and specific for identifying the spectrum of alcohol misuse. Also, it should be easy to recall so it can be part of routine face-to-face discussion with the patient during an office visit.

Further, it should include questions that focus on the consequences of drinking as well as on quantity and frequency. It should also take into account factors such as the patient’s age, sex, race or ethnicity, and pregnancy status, as these can influence the effectiveness of the screening method.

Problems with focusing on quantity alone

“Risky use” is defined (in a non-alcohol-dependent person or one with no alcohol-related consequences) as more than seven standard drinks per week or more than three per occasion for women, and more than 14 standard drinks per week or more than four per occasion for men.²

A standard drink in the United States contains about 12 to 14 g of ethanol: a 12-oz can or bottle of beer, a 5-oz glass of wine, or about 1.5 oz of 80-proof liquor.²

The common single-item screening test asks, “How many times in the past year have you had more than four drinks (for women) or five drinks (for men) in a day?” This is recommended by the National Institute on Alcohol Abuse and Alcoholism for brief screening in primary care. However, a positive answer (ie, one or more times in the past year) has a sensitivity of only 82% and a specificity of only 79% for detecting unhealthy alcohol use, and an even lower specificity (67%) for detecting current alcohol use disorder.⁷

The CAGE questionnaire

The four-item CAGE questionnaire⁸ focuses on the consequences of drinking:

• C: Have you felt the need to cut down on your drinking?
• A: Have you ever felt annoyed by someone criticizing your drinking?
• G: Have you ever felt bad or guilty about your drinking?
• E: Have you ever had an eye-opener—a drink the first thing in the morning to steady your nerves?

A yes to one or more of the questions denotes a need for further assessment.

The CAGE questionnaire is simple, non-threatening, brief, and easy to remember. A yes answer to two or more items has a sensitivity of 75% to 95% and a specificity of 84% to 97% for alcohol dependence.⁹ However, CAGE is less sensitive for identifying nonalcohol-dependent at-risk drinkers. The patient’s sex and ethnicity have also been found to affect its performance somewhat, with some studies showing a sensitivity as low as 50% in adult white women and as low as 40% in at-risk groups ages 60 and over.

 

 

The TWEAK questionnaire

The TWEAK is a modification of the CAGE and includes a question about tolerance; it has a sensitivity of 87% for harmful drinking and 84% for dependence, especially in trauma-related cases.⁹ It has also been found to be better than the CAGE for screening pregnant patients.

• Tolerance: How many drinks can you hold without falling asleep or passing out? (2 points if six drinks or more)
• Worried: Have friends or relatives worried about your drinking? (2 points if yes)
• Eye-opener: Do you sometimes take a drink in the morning when you first get up? (1 point if yes)
• Amnesia: Have friends or relatives told you about things you said or did while drinking that you could not remember? (1 point if yes)
• Cut down: Do you sometimes feel the need to cut down on your drinking? (1 point if yes)

An answer of ≥ 6 to the first question or a total score of 3 or more denotes a problem with alcohol use and a need for further assessment.¹⁰

The AUDIT-C

The AUDIT-C, a shorter form of the 10-item AUDIT developed by the World Health Organization, uses only the first three questions of the full-length AUDIT. The three-item AUDIT-C has a sensitivity ranging from 85% in Hispanic women to 95% in white men.^9,11 The questions center on the quantity and frequency of alcohol use:

• How often do you have a drink containing alcohol? Answer choices: never; monthly or less often; 2 to 4 times a month; 2 to 3 times a week; 4 or more times a week.
• How many standard drinks containing alcohol do you have on a typical day when you are drinking? Answer choices: one or two; three or four; five or six; seven to nine; 10 or more.
• How often do you have six or more drinks on one occasion? Answer choices: never, less than monthly; monthly; weekly; daily or almost.

Scoring is 0 for never, and 1, 2, 3, or 4 for the subsequent answer choices in each question.

The cut-off score for the AUDIT-C is usually a total of 3 points for women and 4 for men: ie, a score of 3 or higher for women and a score of 4 or higher for men indicate alcohol use disorder and the need for further assessment.

The AUDIT questionnaire has been found not only to have a high sensitivity (83%) and specificity (90%) for identifying alcohol dependence, but also to be more sensitive than the CAGE questionnaire (85% vs 75%) for identifying harmful drinking, hazardous drinking, and at-risk drinking. (Note: The full version of AUDIT performed similarly to the three-item AUDIT-C for detecting heavy drinking and active abuse or dependence.¹²) Furthermore, it has performed well as a screening test in many multinational trials of alcohol brief intervention. The questions about quantity of alcohol consumed may be even more suitable for adolescents and young adults, who tend to fall into the harmful-hazardous drinking category rather than the dependent category. In some studies, patients tended to reveal less with the CAGE questionnaire when it was preceded by direct and close-ended questions about the quantity and frequency of alcohol use, thus reducing its sensitivity.¹³

The AUDIT and TWEAK questionnaires showed greater sensitivity in both men and women than the CAGE questionnaire and were equally sensitive in African Americans.¹⁴

HOW TO FIT ALCOHOL SCREENING INTO AN OFFICE VISIT

A practical way to fit alcohol screening into an office visit is to include a questionnaire in the assessment papers completed by the patient while in the waiting room. In other settings, these questions may be asked by trained nursing staff as part of the initial assessment, ie, while obtaining the patient’s weight and vital statistics. This can be briefly reviewed by the physician during the face-to-face history and physical examination.

A concerted effort is needed to proactively screen for alcohol use. A combination of questions about the effect, the quantity, and the frequency of alcohol use is the best way to screen for the many different aspects of alcohol use disorder—many of which can be managed in the primary care setting through brief interventions without referral to a specialist.

When screening for alcohol misuse, it is also important to consider factors such as age, sex, race or ethnicity, pregnancy, and history of recent trauma or surgery.

Popular questionnaires to screen for alcohol misuse include the CAGE, the TWEAK, and the short form of the Alcohol Use Disorder Identification Test (AUDIT-C). Any of these is recommended. The important thing is to be proactive about screening for this very common and underrecognized problem.

A COMMON PROBLEM, NOT OFTEN ADMITTED

Alcohol use disorder, which ranges from hazardous drinking to binge drinking and alcohol dependence, is more common than admitted and often goes undiagnosed. Its personal, societal, and economic consequences cannot be overemphasized. Alcohol use is responsible for 85,000 deaths each year in the United States, and it is linked to substantial medical and psychiatric consequences and injuries, especially motor vehicle accidents. The estimated annual cost of problems attributed to alcohol use is over $185 billion.¹

About three in 10 US adults drink at levels that increase their risk for alcohol-related consequences, and about one in four adults currently abuses alcohol or is dependent on it.² In 2009, 6.8% of the US population age 12 and above reported heavy drinking, with highest rates in those ages 21 to 29.³ The rate of alcohol use was higher in men than in women, but about 10% of pregnant women ages 15 to 44 reported current alcohol use.³

The prevalence of alcohol use disorder ranges from 2% to 29% in a typical ambulatory primary care medical practice.⁴ And only one-third of people with alcohol use disorder are diagnosed.

Studies and experience have shown that problem drinkers tend to not seek help until they have advanced dependence, often with associated medical and sociolegal complications. It is also well established that the earlier the diagnosis is made and appropriate intervention is offered, the better the prognosis.

WHAT IS THE GOAL OF SCREENING?

The goals of screening for alcohol use disorder are to estimate the patient’s risk level, to identify those at risk because they exceed defined limits, and to identify those with evidence of an active problem, ie, with adverse consequences related to their drinking. This screening paves the way for further assessment, definitive diagnosis, and a treatment plan.

The US Preventive Services Task Force recommends screening and behavioral counseling interventions (such as a brief intervention) in the primary care setting to reduce alcohol misuse by adults, including pregnant women.⁵ In addition, most primary care patients who screen positive for heavy drinking or alcohol use disorder show motivation and readiness to change, and those with the most severe symptoms tend to be the most ready.⁶

THE IDEAL QUESTIONNAIRE: SENSITIVE, SPECIFIC, AND SHORT

The ideal alcohol screening questionnaire for a busy practice should be brief and highly sensitive and specific for identifying the spectrum of alcohol misuse. Also, it should be easy to recall so it can be part of routine face-to-face discussion with the patient during an office visit.

Further, it should include questions that focus on the consequences of drinking as well as on quantity and frequency. It should also take into account factors such as the patient’s age, sex, race or ethnicity, and pregnancy status, as these can influence the effectiveness of the screening method.

Problems with focusing on quantity alone

“Risky use” is defined (in a non-alcohol-dependent person or one with no alcohol-related consequences) as more than seven standard drinks per week or more than three per occasion for women, and more than 14 standard drinks per week or more than four per occasion for men.²

A standard drink in the United States contains about 12 to 14 g of ethanol: a 12-oz can or bottle of beer, a 5-oz glass of wine, or about 1.5 oz of 80-proof liquor.²

The common single-item screening test asks, “How many times in the past year have you had more than four drinks (for women) or five drinks (for men) in a day?” This is recommended by the National Institute on Alcohol Abuse and Alcoholism for brief screening in primary care. However, a positive answer (ie, one or more times in the past year) has a sensitivity of only 82% and a specificity of only 79% for detecting unhealthy alcohol use, and an even lower specificity (67%) for detecting current alcohol use disorder.⁷

The CAGE questionnaire

The four-item CAGE questionnaire⁸ focuses on the consequences of drinking:

• C: Have you felt the need to cut down on your drinking?
• A: Have you ever felt annoyed by someone criticizing your drinking?
• G: Have you ever felt bad or guilty about your drinking?
• E: Have you ever had an eye-opener—a drink the first thing in the morning to steady your nerves?

A yes to one or more of the questions denotes a need for further assessment.

The CAGE questionnaire is simple, non-threatening, brief, and easy to remember. A yes answer to two or more items has a sensitivity of 75% to 95% and a specificity of 84% to 97% for alcohol dependence.⁹ However, CAGE is less sensitive for identifying nonalcohol-dependent at-risk drinkers. The patient’s sex and ethnicity have also been found to affect its performance somewhat, with some studies showing a sensitivity as low as 50% in adult white women and as low as 40% in at-risk groups ages 60 and over.

 

 

The TWEAK questionnaire

The TWEAK is a modification of the CAGE and includes a question about tolerance; it has a sensitivity of 87% for harmful drinking and 84% for dependence, especially in trauma-related cases.⁹ It has also been found to be better than the CAGE for screening pregnant patients.

• Tolerance: How many drinks can you hold without falling asleep or passing out? (2 points if six drinks or more)
• Worried: Have friends or relatives worried about your drinking? (2 points if yes)
• Eye-opener: Do you sometimes take a drink in the morning when you first get up? (1 point if yes)
• Amnesia: Have friends or relatives told you about things you said or did while drinking that you could not remember? (1 point if yes)
• Cut down: Do you sometimes feel the need to cut down on your drinking? (1 point if yes)

An answer of ≥ 6 to the first question or a total score of 3 or more denotes a problem with alcohol use and a need for further assessment.¹⁰

The AUDIT-C

The AUDIT-C, a shorter form of the 10-item AUDIT developed by the World Health Organization, uses only the first three questions of the full-length AUDIT. The three-item AUDIT-C has a sensitivity ranging from 85% in Hispanic women to 95% in white men.^9,11 The questions center on the quantity and frequency of alcohol use:

• How often do you have a drink containing alcohol? Answer choices: never; monthly or less often; 2 to 4 times a month; 2 to 3 times a week; 4 or more times a week.
• How many standard drinks containing alcohol do you have on a typical day when you are drinking? Answer choices: one or two; three or four; five or six; seven to nine; 10 or more.
• How often do you have six or more drinks on one occasion? Answer choices: never, less than monthly; monthly; weekly; daily or almost.

Scoring is 0 for never, and 1, 2, 3, or 4 for the subsequent answer choices in each question.

The cut-off score for the AUDIT-C is usually a total of 3 points for women and 4 for men: ie, a score of 3 or higher for women and a score of 4 or higher for men indicate alcohol use disorder and the need for further assessment.

The AUDIT questionnaire has been found not only to have a high sensitivity (83%) and specificity (90%) for identifying alcohol dependence, but also to be more sensitive than the CAGE questionnaire (85% vs 75%) for identifying harmful drinking, hazardous drinking, and at-risk drinking. (Note: The full version of AUDIT performed similarly to the three-item AUDIT-C for detecting heavy drinking and active abuse or dependence.¹²) Furthermore, it has performed well as a screening test in many multinational trials of alcohol brief intervention. The questions about quantity of alcohol consumed may be even more suitable for adolescents and young adults, who tend to fall into the harmful-hazardous drinking category rather than the dependent category. In some studies, patients tended to reveal less with the CAGE questionnaire when it was preceded by direct and close-ended questions about the quantity and frequency of alcohol use, thus reducing its sensitivity.¹³

The AUDIT and TWEAK questionnaires showed greater sensitivity in both men and women than the CAGE questionnaire and were equally sensitive in African Americans.¹⁴

HOW TO FIT ALCOHOL SCREENING INTO AN OFFICE VISIT

A practical way to fit alcohol screening into an office visit is to include a questionnaire in the assessment papers completed by the patient while in the waiting room. In other settings, these questions may be asked by trained nursing staff as part of the initial assessment, ie, while obtaining the patient’s weight and vital statistics. This can be briefly reviewed by the physician during the face-to-face history and physical examination.

A concerted effort is needed to proactively screen for alcohol use. A combination of questions about the effect, the quantity, and the frequency of alcohol use is the best way to screen for the many different aspects of alcohol use disorder—many of which can be managed in the primary care setting through brief interventions without referral to a specialist.

When screening for alcohol misuse, it is also important to consider factors such as age, sex, race or ethnicity, pregnancy, and history of recent trauma or surgery.