Screening For Substance Use Christopher Welsh M.D. & Carlo DiClemente Ph.D.

Screening For Substance Use
Christopher Welsh M.D.
&
Carlo DiClemente Ph.D.
Why Screen?
 To detect current tobacco, at-risk alcohol and
substance use at an early stage before they result in
more serious academic, social or health problems
 Screening guides decision-making (it does not yield a formal
diagnosis)
 To connect substance use to current academic, social
and health problems and future health risks
 To find out how alcohol and other substance use
could interfere with other treatments
Scope of the Problem:
Tobacco Use
 Exposure to secondhand smoke killed an estimated 430
newborns from sudden infant death syndrome in 2005.
 If either parent smokes, the risk of childhood asthma is
increased by 40%.
 About one-quarter (24.9 percent) of all children
aged 3–11 years and one-fifth (19.9%) of youth
aged 12–19 live with at least one smoker in the home.
Source: Burke et al. (2012); Smokefree Families’ Helping Families Thrive: Key Policies to
Promote Tobacco-Free Environments for Families (2009)
http://tobacco-cessation.org/sf/pdfs/pub/Final%20Final%20Indicator%20with%20all%20edits%203-30-09.pdf
Scope of the Problem in Pediatrics
Leading Causes of Mortality
Ages 10-24, United States, 2007
The 4 leading causes of mortality among adolescents
shown above are all linked to alcohol and other drug use.
Adapted from Children's Hospital Boston SBIRT Training Curriculum (www.CeASAR.org); Eaton DK et al.
(2008) Youth risk behavior surveillance-United States, 2007. MMWR Surveill Summ, 57(4):1-131.
Top Causes of Death
15-19 year olds (2010)
The 4 leading causes of mortality among
adolescents shown above are all linked to
alcThe 4 leading causes of mortality among adolescents shown
above are all linked to alcohol and other drug use.

ohol and other drug use.
The top 3 causes are all significantly
related to drug & alcohol use
io
Scope of the Problem in Pediatrics
Alcohol Involvement in Fatal Motor
Vehicle Crashes - United States, 2009
Age
Fatalities
Percentage with Blood Alcohol
Concentration .08 or Greater
16 – 20
(n = 5,051)
19%
21 – 24
(n = 4,597)
35%
U.S. Census Bureau, Statistical Abstract of the United States: 2012.
Scope of the Problem in Pediatrics
Substances Used by12th Graders – Nationally, 2011
Lifetime %
Past 30 days %
Alcohol (any)
70%
40%
Alcohol (been drunk)
51%
25%
Cigarettes
40%
19%
Any drug
51%
27%
Marijuana/Hashish
46%
23%
Any drug other than Marijuana
25%
9%
Amphetamines
12%
4%
Inhalants
8%
1%
Hallucinogens
8%
2%
Cocaine
5%
1%
Heroin
1%
<1%
Any Prescription Drug
22%
7%
Adapted from Children's Hospital Boston SBIRT Training Curriculum (www.CeASAR.org); Johnston LD et al.
Monitoring the Future - National results on adolescent drug use: Overview of key findings, 2011.
www.monitoringthefuture.org
Scope of the Problem in Pediatrics
Substances Used by 9th -12th Graders – Maryland, 2009
Lifetime
Past 30 days
Alcohol (any)
67%
37%
Alcohol (been drunk)
19%
Cigarettes
~
44%
Marijuana/Hashish
36%
22%
Amphetamines
4%
~
Inhalants
11%
~
Hallucinogens
8%
~
Cocaine
6%
3%
Heroin
4%
~
*Nonmedical use of pain relievers
6%
~
12%
Centers for Disease Control and Prevention . (2010). Youth Risk Behavior Surveillance Survey – Maryland, 2009;
* Ages 12 – 17, 2006-2007. Pain reliever data are from: U.S. Department of Health and Human Service. (2010)
Results from the 2006 and 2007 National Survey on Drug Use and Health.
Scope of the Problem in Pediatrics
Alcohol Associated Risk Behaviors,
Grades 9-12 -- Maryland, 2009
During the past 30 days:
– 67% reported drinking
– 10% reported heavy-drinking (>5 drinks)
– 9% drove a vehicle after drinking
– 27% rode with a driver who had been drinking
Adapted from Children's Hospital Boston SBIRT Training Curriculum (www.CeASAR.org);
Centers for Disease Control and Prevention. (2010).
Youth Risk Behavior Surveillance Survey – Maryland, 2009
Scope of the Problem in Pediatrics
Prevalence of Lifetime Diagnosis of Alcohol Dependence
By Age that Youth Began Drinking
Adapted from Children's Hospital Boston SBIRT Training Curriculum (www.CeASAR.org);
Hingson RW et al. (2006). Arch Pediatr Adolesc Med, 160(7), 739-746.
“IF YOU’VE SEEN ONE
PERSON WITH
ADDICTION, YOU’VE
SEEN ONE PERSON WITH
ADDICTION.”
Before You Screen…
 Before screening, review the confidentiality policy in
your setting with both patients and parents
 Include the safety-related limits that may justify you
breaking confidentiality
 Check your state laws for guidelines on breaking
confidentiality
 Review patient’s family and social history in the chart
 Screen adolescents age 12 or older alone
 Patients are more likely to be honest when substance use
screening is confidential and parents or guardians are not
present
Timing the Substance Use Screen






Ask about prescription medications first & then move on
to OTCs & more socially-acceptable substances like
caffeine then tobacco, alcohol and illicit substances
Ask about family history of alcohol or drug abuse first &
then ask about the student’s use
Ask about general health habits such as sleep, exercise &
diet first and then get into OTC drugs, caffeine,
tobacco, etc.
Ask about leisure activities/hobbies
Ask about stressors and ways of coping
Ask about substance use whenever student brings
it up for another reason
Helpful Screening Hints
 Assure the patient that you are asking
because of your concern for his/her
health and well being.
 Have a non-judgmental attitude!
 Be aware of your own preconceptions
about substance use & abuse
 Acknowledge that you recognize that
some information is difficult to talk about
Helpful Screening Hints
 Ask “technical” terms first; use “slang” if student doesn’t
seem to understand
 Pay attention to the manner in which the student responds
as well as the content
 Acknowledge discomfort (e.g., “You seemed to get
annoyed when I asked that.”)
 Always follow-up on “qualified answers”
 Be persistent
Non Verbal Cues
 Watch for both non-verbal cues in the student’s behavior
and non-verbal interactions between students and their
parents
 Interpret significant changes in a student's non-verbal cues
as a potentially positive screen for misuse or abuse:
 Eye contact
 Posture
 Movements
 Fluidity and tone of
speech
 Affect
DENIAL
 LYING
LYING
 SUBSTANCE
ABUSER
Screening for the
Following Substances:




Tobacco Use
Alcohol Misuse
Illicit Drug Use
Prescription Drug Misuse
 Problematic Gambling
Screening: Who, When, & Why
Patient
Age
Who to What to
Screen Screen
Reasons for Screening
0 - 4 years
Parents
Tobacco
• Secondhand smoke (SHS) increases risk of
SIDS, bronchiolitis, meningitis
5 - 8 years
Parents &
Patients
Tobacco
• SHS & smoking raises risk of asthma,
pneumonia, bronchitis, middle-ear infections
Parents &
9 - 11 years
Patients
Tobacco,
Alcohol
• Same risks for SHS & smoking as above
• Alcohol use increases risk for injuries, later alcohol
dependence, & brain changes
12+ years
Parents &
Patients
Tobacco,
• Substance use linked to injuries & death, suicide,
Alcohol,
aggression & victimization, infections, unplanned
Illicit drug use,
pregnancy, academic & social problems
Rx drug use
Sources: AAP (2011) Policy Statement: Substance Use Screening, Brief Intervention, and Referral to Treatment for
Pediatricians; NIAAA (2011) Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.
Types of Screening
Primary Screen:

Initial set of screening questions specific to each
type of substance: Tobacco, Alcohol, Illicit Drugs,
and Misuse of Prescription Drugs
Secondary Screen:

Also known as a formal screen in which a
standardized screening tool is used to detect the
level of risk of the person’s substance use
Lindsay
Lohan
Tobacco Products
Screening for Parent Tobacco Use:
0 – 4 years old
 Ask the patient’s parent(s) about tobacco
and secondhand smoke (SHS) exposure
 “Do you smoke?”
 “Where do you smoke?”
 “Is the child exposed to tobacco smoke anywhere else?”
 Ask specifically about in-home child care providers, family
and other household members
 Ask at all clinical encounters, including nursery visits, welland sick-child visits, whether inpatient or outpatient
Adapted from AAP (2009) Policy Statement: Tobacco Use: A Pediatric Disease
and the AAP Richmond Center’s presentation: “Promoting Smoke-free Families,”
http://www2.aap.org/richmondcenter/PowerpointPresentations.html
Screening for Parent Tobacco Use:
5 – 8 years old
 Continue to ask at all clinical encounters
 The AAP (2009) Tobacco Use Policy Statement recommends
discussing and offering anticipatory guidance to patients about
tobacco use as they get older
 For parents:
 Continue to ask about tobacco & SHS exposure
 Emphasize that if they smoke, they are
modeling smoking for their child
 For parents and patients:
 If appropriate, emphasize resisting the influence
of advertising and rehearsal of peer-refusal skills
Adapted from AAP (2009) Policy Statement: Tobacco Use: A Pediatric Disease
and the AAP Richmond Center’s presentation: “Promoting Smoke-free Families”
Screening for Parent & (if concern) Patient Tobacco Use:
9 – 11 years old
 Continue to ask parent(s) at all clinical encounters
 Continue to ask the patient’s parent(s) about tobacco and
SHS exposure (see previous slides for specific questions)
 Emphasize resisting the influence of
advertising and rehearsal of
peer-refusal skills
 If there’s concern, including if anyone in
the home smokes, you could ask patients:
“Do you have any friends who smoke cigarettes?”
“Have you ever tried smoking?”
Adapted from AAP (2009) Policy Statement: Tobacco Use: A Pediatric Disease
and the AAP Richmond Center’s presentation: “Promoting Smoke-free Families”
Screening for Parent & Patient Tobacco Use:
12+ years old
ASK both patients & their parent(s):
 “Have you ever smoked cigarettes or used other
tobacco products?”
 “Have you smoked even a puff of a
cigarette or used other tobacco products
in the past 30 days?”
 If yes: “On average, how many cigarettes
did/do you smoke per day?”
 If yes: “How long have you been smoking
at that rate (in years)?”
Adapted from the NIDA Quick Screen and guided by
Treating Tobacco Use and Dependence: Clinical Practice Guideline, 2008 Update (Fiore et al., 2008).
Opening Questions:
Ages 9-11, Alcohol Only
 Alcohol screening guidelines are age-specific:
 For patients ages 9-11, asking about their friends’
alcohol use first is a less threatening, side-door
opener to the topic of drinking alcohol.
 When you have less of a connection with a patient or
the patient is more reluctant, starting with questions
about his/her friends’ use may be helpful as well.
 Always follow with questions about the
student’s use.
Source: NIAAA (2011) Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.
Opening Questions:
Ages 9-11, Alcohol Only
 Start with FRIENDS’ use:
“Do you have any friends who have ever drunk beer, wine,
or any drink containing alcohol?”
 Then ask about STUDENT’S use:
“How about you—have you ever had more than a few sips
of beer, wine, or any drink containing alcohol?”
Sources: NIAAA (2011) Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.
Opening Questions:
Ages 12 and older
Ask about the student’s use:
“Have you ever…
…drunk any alcohol (more than a few sips), including
beer or wine?”
…smoked any marijuana, or used cocaine or any other
substances to get high, like huffing things like glue or paint?”
…used any prescription medications that weren’t yours
or in a way that wasn’t prescribed?”
Sources: AAP (2011) Policy Statement: Substance Use Screening, Brief Intervention, and Referral to Treatment for
Pediatricians; NIAAA (2011) Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.
Screen For Children & Adolescents:
Alcohol
Grade Level/Age
1st Question
Elementary School
(ages 9-11)
“Do you have any friends
who drank beer, wine or
any drink containing alcohol
in the past year?
(Any “Yes” is +)
Middle School
(ages 11-14)
High School
(ages 14-18)
2nd Question
“How about you- have you
ever had more than a few
sips of beer, wine, or any
drink containing alcohol?”
(Any “Yes” is +)
“How about you- in the past
“Do you have any friends
year, on how many days
who drank beer, wine or
have you had more than a
any drink containing alcohol
few sips of beer, wine, or any
in the past year?
drink containing alcohol?”
(Any “Yes” is +)
(Any # is +)
“In the past year, on how
“If your friends drink, how
many days have you had
many drinks do they usually
more than a few sips of
drink on an occasion?”
beer, wine or any drink
(3-5 drinks is +)
containing alcohol?”
(Any # is +)
Screening  Brief Intervention
for Alcohol & Other Substance Use
After Tobacco
Screening…
Opening
Questions:
“Have you ever:
• drunk any alcohol
(more than a few
sips), including beer
& wine?
• smoked any
marijuana, or used
cocaine or any
other substances to
get high, like
huffing things like
glue or paint?
• used any
prescription
medications that
weren’t yours or in
a way that wasn’t
prescribed?”
No to All
•Praise & encouragement
•CRAFFT “CAR” Question
CRAFFT
= 0 or 1
Brief
Advice
•Administer the CRAFFT
C = “Have you ever ridden in a CAR
Yes to Any
driven by someone (including yourself)
who had been using alcohol or drugs?”
R = “Do you ever use alcohol or drugs to
RELAX, feel better about yourself
or to fit in?”
A = “Do you ever use alcohol or drugs
while you are ALONE?”
F = “Do you ever FORGET things you did
while using alcohol or drugs?”
F = “Does your FAMILY or FRIENDS ever
tell you that you should cut down on
your drinking or drug use?”
T = “Have you ever gotten into TROUBLE
while you were using alcohol or drugs?”
CRAFFT
≥2
“5 A’s”
in the
office
Adapted from AAP (2011) Policy Statement: SBIRT for Pediatricians
Brief
Intervention
Refer to
Treatment
Make an
Immediate
Intervention
Answers to Opening Questions:
Ages 12 and older
NO
YES
 Ask CAR question of CRAFFT
 Reinforce healthy choices
 If friends use substances:
 Administer full CRAFFT to
determine the adolescent’s risk
level for a substance use
problem
 Explore patient’s views on this
 Ask about plans to stay substance-free
 Rescreen at next visit
 If friends don’t use substances:
 Praise the choice of substance-free friends
 Elicit and affirm reasons for staying
substance use free
 Rescreen at next year
Sources: AAP (2011) Policy Statement: Substance Use Screening, Brief Intervention, and Referral to Treatment for
Pediatricians; NIAAA (2011) Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.
Secondary Screening Tool for
Adolescents: CRAFFT






Screener for adolescents
Validated for youth between 12 and 21 years old
6 yes/no questions
Administered by interview
Can be worded to include alcohol and drugs
Even if they say no to the Opening Questions, still
ask the first “CAR” question
 1 (or 2) positive answers is a positive screen
To download the CRAFFT, please click the “Attachments” tab above.
CRAFFT Questions
C=
“Have you ever ridden in a CAR driven by someone (including
yourself) who had been using alcohol or drugs?”
R=
“Do you ever use alcohol or drugs to RELAX, feel better about
yourself or to fit in?”
A=
“Do you ever use alcohol or drugs while you are ALONE?”
F=
“Do you ever FORGET things you did while using alcohol or drugs?”
F=
“Does your FAMILY or FRIENDS ever tell you that you should cut
down on your drinking or drug use?”
T=
“Have you ever gotten into TROUBLE while you were using
alcohol or drugs?”
Source: http://www.ceasar-boston.org/CRAFFT/screenCRAFFT.php
http://youtu.be/QXnjeFY7Lu0
Classification of Risk
Risk Level:
Screening Results:
LOW
“NO” to all Opening Questions
MODERATE
“YES” to 1 or more of Opening Questions and
CRAFFT score = 0 or 1
HIGH
“YES” to 1 or more of Opening Questions and
CRAFFT score ≥ 2
Source: AAP (2011) Policy Statement: Substance Use Screening, Brief Intervention, and
Referral to Treatment for Pediatricians
CRAFFT’s
Positive Predictive Value
Dx Abuse or Dependence
(N = 538)
100%
80%
60%
40%
20%
0%
1
2
3
4
5
6
CRAFFT SCORE
Sources: Children’s Hospital Boston (2010) SBIRT Overview Presentation;
Knight JR et al. Arch Pediatr Adolesc Med. 2002;156:607-614.
Secondary Tobacco Screen
Fagerström Test for Nicotine Dependence:
6 questions with Likert scale responses:
1. How soon after you wake up do you smoke your first cigarette?
After 60 minutes (0) 31-60 minutes (1) 6-30 minutes (2) Under 5 minutes (3)
2. Do you find it difficult to refrain from smoking in places where it is forbidden?
No (0) Yes (1)
Scoring: Add up the numbers in
3. Which cigarette would you most hate to give up?
(parentheses) after each of the
First in the morning (1) Any other (0)
answers for the 6 questions.
4. How many cigarettes per day do you smoke?
0 - 2 = Very low dependence
10 or less (0) 11-20 (1) 21-30 (2) 31 or more (3)
3 - 4 = Low dependence
5 = Medium dependence
5. Do you smoke more frequently during the first hours after
waking than during the rest of the day?
6 - 7 = High dependence
8 - 10 = Very high dependence
No (0) Yes (1)
6. Do you smoke even if you are so ill that you are in bed
most of the day?
No (0) Yes (1)
Secondary Alcohol
Screen: AUDIT
45









10 questions - multiple choice
Administered in writing
Alcohol only
Screens for at-risk drinking, abuse, dependence
Accurate across many cultures/nations
All questions except 9 & 10 refer to past year
Questions 1-8 are scored 0,1,2,3,4; Questions 9 and 10
are scored 0,2,4.
(A score of 8 or more indicates a strong likelihood of
hazardous/harmful use)
Sens: 51% - 97% Spec: 78% - 96%
Secondary Alcohol Screen: AUDIT
What is a “Standard Drink”?
Assessing Alcohol Quantity
 Ask about beer and wine specifically.
 Ask if the “bottle” (pint, fifth, etc.) is beer, wine or
liquor.
 Ask how many ounces or how big “a drink” is
(can have patient gesture with hands).
 Beer bottles/cans come in ounces and mls/liters.
 Wine and liquor bottles come in mls/liters.
 Several names are often used to describe different
sizes of bottles
1 fluid ounce≈30mls (milliliters)
What is a “Standard Drink”?
A “STANDARD DRINK”
(a standard drink contains approximately 12-14 grams or 0.5-0.6 oz of pure alcohol)
Beer
(3-5%)
Malt liquor
(7-10%)
Table wine
(12-13%)
(Budweiser,
Miller, Coors,
Heineken,
Corona)
(Steele Reserve,
Colt 45, King Cobra,
Camo 40, Black
Bull, Hurricane,
Mickey’s, Private
Stock)
(Chardonnay,
Merlot,
Pinot Grigio,
Reisling,
Sangria)
12oz.
6-8oz.
“Double Deuce”= 2 drinks
“Quart”= 2 ½ drinks
“40” of beer = 3-4 drinks
“40” of malt liquor = 6-7 drinks
5oz.
Fortified wine,
port, sherry
(18-20%)
(Mad Dog 20/20,
Night Train
Express,
Richards Wild
Irish Rose,
Thunderbird)
3.5 oz.
“Pint”= 2 ½ drinks
“Pint” of FW= 4 drinks
“Fifth”= 5 drinks
“Fifth” of FW= 7 ½ drinks
Brandy
(37-40%)
(Cognac,
Hennessey,
Courvoisier,
Remy Martin)
1.5 oz.
Liquor
(a “shot”)
(40%)
(vodka, gin,
scotch,
whiskey,
bourbon,
tequila, rum)
1.5 oz.
“Half Pint”= 4 ½ drinks
“Pint”= 8 ½ drinks
“Fifth”= 17 drinks
“Handle”= 40 drinks
Not Everyone Drinks In
“Standard” Ways
Primary Screen: Rx Drug Misuse
 Although many people take medications that are not
prescribed to them, we are primarily concerned with:
 Opioids (oxycodone, buprenorphine, hydrocodone,
fentanyl, methadone)
 Benzodiazepines (clonazepam, alprazolam, diazepam)
 Stimulants (amphetamine, dextroamphetamine,
methylphenidate)
 Sleep aids (zolpidem, zaleplon, eszopiclone)
 Other assorted (clonidine, carisoprodol)
Primary Screen: Rx Drug Misuse
 “Have you ever taken any prescription medication
that was not prescribed for you?”
 “Have you ever taken any prescription medication in
ways not prescribed (used more or less than what
was prescribed for you)?” or
 “Have you ever taken any prescription medication
only for the feeling or experience they caused?”
Levels of Risk: Rx Drugs
 Non-medical use of controlled substances
(opioids, benzodiazepines, stimulants) should lead
to an attempt to discern if the use is primarily
“self medication” or “recreational.”
 Any non medical use is potentially problematic
and should be addressed with a brief intervention.
 This should always be taken into account when
prescribing a controlled substance to a patient.
Primary Screen: Illicit Drugs
 “Have you ever used drugs such as marijuana, heroin,
cocaine, LSD, PCP, methamphetamine, etc?”
 If YES, ask:




“Which drugs have you used in the last 3 months?”
“How much are you using per day?”
“When did you last use?”
“Have you ever used drugs by injection?”
Levels of Risk: Illicit Drugs
 Any drug use should be addressed with
a brief intervention and/or referral to
treatment.
 Recommend HIV & Hepatitis B & C
testing for any injection drug use.
Longer Screens
(Substance Use & Mental Health)




Drug Use Screening Inventory (DUSI)
Global Appraisal of Individual Needs (GAIN)
Diagnostic Interview Schedule for Children (DISC)
Problem Oriented Screening Instrument for
Teenagers (POSIT)
 Substance Abuse Subtle Screening Inventory for
Adolescents (SASSI-A)
 Detection of Alcohol and Drug Problems in
Adolescents (DEP-ADO)
 Rutgers Alcohol Problem Index (RAPI)
Screening In Adolescence:
Problem Gambling


SOGS-RA
Canadian Adolescent Gambling Inventory
Canadian Problem
Gambling Index
Screening: Summary
Final Notes:
 Screening is the first step of the SBIRT process
and determines the severity and risk level of
the patient’s substance use.
 The result of a screen allows the provider to
determine if a brief intervention or referral to
treatment is a necessary next step for the
patient.
BRIEF INTERVENTIONS
Primary Screen: Tobacco
Tobacco:
 “Have you ever smoked cigarettes or used other
tobacco products?”
 “Have you smoked even a puff of a
cigarette or used other tobacco products
in the past 30 days?”
 If yes: “On average, how many cigarettes
did/do you smoke per day?”
 If yes: “How long have you been smoking
at that rate (in years)?”
Primary Screen: Alcohol
 “How often did you have a drink containing alcohol,
even beer or wine, in the past year?”
If any at all, ask:
 “How many drinks containing alcohol do you have on
a typical day when you do drink?”
 “How often did you have 5 (for men)/4 (for women
& elderly) or more drinks on one occasion in the past
year?”
Levels of Risk: Alcohol
Drinks/Week
Drinks/Occasion
Men
More than 14
More than 4
Women
More than 7
More than 3
65+
More than 7
More than 3
 Patients drinking above these recommended levels could be
putting themselves at risk for illness or injury. Their alcohol use
should be addressed with a secondary screen and/or a brief
intervention.
 Patients with high physical dependence may need
medication to manage withdrawal.
Secondary Screening
 The Secondary Screen is a screening tool used to
better garner information about the history, current
use pattern, and level of risk of the patient
(e.g., the ASSIST, the AUDIT, and the CRAFFT).
 If the Primary Screen is positive, you or someone
else in your office can conduct a Secondary screen
to further assess for problematic substance use.
Secondary Alcohol Screen: CAGE
C – “Have you ever felt you should cut down on your drinking?”
A – “Have people annoyed you by criticizing your drinking?”
G – “Have you ever felt bad or guilty about your drinking?”
E – “Have you ever had a drink first thing in the morning to
steady your nerves or to get rid of a hangover?” (Eye opener)
The CAGE can identify alcohol problems over the lifetime.
Two positive responses are considered a positive test and
indicate further assessment is warranted.
AUDIT
68

How often do you have a drink containing alcohol?
Never

Two to three
Four or more
or less
times a month
times a week
times a week
3 or 4
5 or 6
7 to 9
Less than Monthly
Monthly
Weekly
Daily or almost daily
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
Weekly
monthly

10 or more
How often do you have 5 or more drinks on one occasion?
Never

Two to four
How many drinks containing alcohol do you have on a typical
day when you do drink?
1 or 2

Monthly
Daily or
almost daily
How often during the last year have you failed to do what was
normally expected from you because of drinking?
Never
Less than Monthly
Monthly
Weekly
Daily or almost daily
AUDIT(cont)
69

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
Weekly
Daily or almost daily
monthly

How often during the last year have you had a feeling of guilt or
remorse after drinking?
Never
Less than
Monthly
Weekly
Daily or almost daily
monthly

How often during the last year have you been unable to remember
what happened the night before because you were drinking?
Never
Less than
Monthly
Weekly
Daily or almost daily
monthly

Have you or someone else been injured as a result of your
drinking?
No

Yes, but not in the last year
Yes, during the last year
Has a relative or a friend, or a doctor or other health worker, been
concerned about your drinking or suggested you cut down?
No
Yes, but not in the last year
Yes, during the last year
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