Toolbox - AUDIT for alcohol use disorders
GP Dr Carsten Grimm’s quick-fire advice on how and when to use this tool in primary care
The AUDIT (Alcohol Use Disorder Identification Test) is used to determine whether a patient suffers from alcohol use disorder (AUD). It is regarded as the gold standard in AUD screening and takes less than 10 minutes to complete. Several shorter versions like the AUDIT-C, AUDIT-PC and FAST have been developed and can be used if you need to save time in a consultation.
When to use it
The AUDIT is used in nearly all clinical scenarios and is well validated in primary care.1 It requires minimal training, a basic knowledge of alcohol units and a good rapport from the patient. Training is available online via different well-evaluated resources.2,3
It is useful for both screening and initial diagnosis, and several local and national incentives (DES and LES) are promoting its use in primary care.
AUDIT-C consists of the first three questions of the AUDIT.4,5
- How often do you have a drink containing alcohol?
- How many units of alcohol do you drink on a typical day when you are drinking?
- How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
If these are positive, the full AUDIT must be done – you can download a version of the full AUDIT tool here. The lack of specificity of AUDIT-C would produce too many false positives.
The flowchart illustrates how the AUDIT should be used in practice and the possible outcomes. The Department of Health promotes a slightly different terminology – it is down to personal preference, which one to use:
|WHO||Department of Health||Within recommended limit||Evidence of harm||Intervention|
|Low risk drinking||Yes||No||No|
|Hazardous||Increased risk||No||No||Brief Intervention|
|Harmful||Higher risk||No||Yes||Further Assessment|
The outcome of screening is threefold – either patients don’t require any intervention and should receive positive feedback, a brief intervention or a further assessment.
Positive feedback does not require much but to inform the patient that their drinking habits are of no concern and are unlikely to cause any serious harm in the future.
Although there is no standard definition of a brief intervention, it entails a wide range of feedback given. This can range from simple structured advice to handing out a leaflet. It is important that the brief intervention is relevant to the patient, for example older patients will likely be interested in how alcohol consumption negatively affects their risk of developing chronic diseases. This table compares the relative risk increase to develop physical health problems of patients who drink to a harmful level compared to low risk:
It is now generally accepted that harmful drinking should result in a further, more detailed assessment. This should include a brief physical health review to look for hypertension, clinical signs of liver disease and blood tests (LFTs). It is good practice to screen for alcohol dependence using a validated tool like SADQ or LDQ. This is often out of the remit of primary care and is done either together with a specialist service provider, but can be done in house by appropriately trained staff like practice nurses.
AUDIT and AUDIT-C have been in use worldwide for the last 20 years. They have largely superseded older screening tools like CAGE due to greater sensitivity and specificity. Although their sensitivity and specificity varies considerably depending on setting and gender, they are the best tool to use in UK primary care. When implemented correctly, outcomes of screening and brief interventions are good, and about 1:8 patients will change their drinking habit. This is compared to 1:10 for smoking cessation programs.
It is important to use AUDIT as part of an integrated care pathway. Alcohol concern plan to publish a tool for GPs and commissioners on their website in the near future.
Dr Carsten Grimm is a GP and clinical lead for Alcohol Treatment Service, Locala CIC, Kirklees
1 Barbor et al: The Alcohol Use Disorder Identification Test – Guidelines for use in Primary Care, WHO, 2001
3 RCGP e-learning (http://www.elearning.rcgp.org.uk/)
4 Saunders JB, Aasland OG, Babor TF et al. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on early detection of persons with harmful alcohol consumption—II. Addiction, 1993; 88 (6): 791-804
5 Bradley KA, DeBenedetti AF, Volk RJ et al. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcoholism, Experimental and Clinical Research, 2007; 31 (7): 1208-1217