Assessment tools: alcohol

1. Assessment tools:
Alcohol

2. Why screen for substance use?
(NICE, 2010)
Systematic reviews explored by NICE
indicated that early intervention in
alcohol use reduces alcohol related
mortality, morbidity, and social
consequences of harmful use.
Also, they support evidence that integrating screening and advice into
general lifestyle discussions may increase the acceptability of
screening and brief intervention.

3. Screening and assessing for
alcohol misuse
Let’s look at some resources available for non-
substance use specialist health and social care
practitioners to carry out brief screening and
assessment for hazardous or harmful alcohol
use.

4. Measuring alcohol use and ‘units’
• Units are a simple way to measure the amount of alcohol in a drink.
• UK Government guidelines advise drinking no more than 14 units
each week to avoid increased risks to health (DH 2016).
• One unit is 8g or 10mls of pure alcohol.
• One unit is the amount most adults can process in one hour.
• So, if you drink one unit per hour, your alcohol level is (theoretically)
going to remain stable.
• However, people tend to process alcohol at different rates – so the 1
unit/hour is not a strict rule!
• How much alcohol in a drink depends on the concentration
of the alcohol.
• So a ‘short’ is more concentrated than, say, a pint of beer.
• It is not the amount of liquid drunk, but the amount of
alcohol in the drink.
• This can be easily calculated using the alcohol volume and liquid
amount given on the label. However, it is easier to use a ‘rough guide’.

5. Rough guide to units (NHS Choices, 2015)
Wine
– 1 small pub standard glass = 1.5 units
– 1 large pub standard glass = 3 units
Beer
– Half pint low strength beer = 1 unit
– Pint of higher strength beer = 3 units
Spirits
– 1 pub measure of whisky/vodka etc = 1 unit
– Typical home measure of whisky/vodka etc > 2 units*
* home measured alcohol is typically much bigger than measured
amounts in a pub or club.

6. Calculating units
To calculate units contained in a drink, just follow the formula
– Strength (ABV%) x Volume (ml) ÷ 1000 = units.
Find a can of beer or bottle of wine in your house or in a shop. Check the
amount in the container (i.e. 568ml) and the alcohol volume (i.e. ABV
5.2%).
Here’s a worked example below:
5.2 (%) x 568 (ml) ÷ 1,000 = 2.95 units
There are online calorie counters which might be easier and you can do
them on your phone.
Try the Alcohol Concern unit calculator. It will also estimate the calories in
each drink.
http://www.alcoholconcern.org.uk/help-and-advice/help-and-advice-with-your-drinking/unit-
calculator/?gclid=Cj0KEQjw04qvBRC6vfKG2Pi0_8gBEiQAAJq0vSWu8E_eYmBlBsrufiLHZSS
9gDULT83b1dYqJuYLGLgaAjul8P8HAQ

7. Screening tools: alcohol
(NICE 2010)
• The main recommended screening tool for alcohol in most non-
specialist settings is the Alcohol Use Disorders Identification Test
(AUDIT) .
• AUDIT is helpful to non-substance specialist practitioners in that it can
help them to evaluate if someone would benefit from reducing their
alcohol consumption.
• AUDIT is a 10 item questionnaire and is scored according to the
answers given.
• The scores indicate the following:
– 1-7 = low-risk drinking
– 8-15= hazardous drinking
– 16-19= harmful drinking
– 20+ = possible dependence.

8. AUDIT: its use
• Babor et al (2001) recommend that AUDIT screening is used
following explanation of the reasons for its use and with key terms
explained.
• For instance, examples of a typical ‘unit’ of
alcohol should be explained.
• Also, after questions 1 or 3, there may be no need to continue if the
person has answered minimally to their use.
• Find a copy and user manual at Public Health England’s website:
http://www.alcohollearningcentre.org.uk/Topics/Browse/BriefAdvice/?pa
rent=4444&child=4896

9. AUDIT: critique
• Go to the Public Health England link on a previous slide and
complete the AUDIT tool yourself.
• How easy were the questions?
• How easy would they be to use in an
assessment with one of your service users?
• How might you adapt it to make it easier to use?

10. AUDIT: what next?
• Babor et al. (2001) recommend the following action dependent on
the person’s score:
 0-7 Alcohol education.
 8-15 Simple advice on healthier alcohol use.
 16-19 Simple advice plus brief intervention and continued
monitoring.
 20-40 Referral to specialist for diagnostic evaluation and
treatment.

11. FAST (fast alcohol screening test)
• The Fast Alcohol Screening Test (FAST) is a simpler test that you
can use to check whether drinking has reached hazardous levels.
• A FAST score of three or more indicates that you're
drinking at a hazardous level.
• Go to the FAST test and try it for yourself.
• How would you use this in your practice?

12. Screening vulnerable groups
• NICE (2010) recommend that some groups may be more
vulnerable to alcohol or screening errors.
• Their screening may require either more careful or an adapted
assessment depending on their needs.
Women who are pregnant or considering pregnancy
– Women who are, or very likely to become, pregnant should
be advised not to drink at all at this time. See the resource on
‘Specific issues in pregnancy’ for more on this.

13. Screening vulnerable groups (cont.)
• Younger people
– People under the age of 16 are more vulnerable to the
effects of alcohol, both physically and behaviourally.
Therefore their risks are higher. A lower score on a
screening test does not mean their drinking is not harmful.
– Gillick and Fraser principles apply to anyone under 16.
Practitioners should encourage inclusion of parents or
guardians when assessing risk from substances.
– For more on this, see the resource Working with young
people and families.

14. Screening vulnerable groups (cont.)
People over 65 years of age
– Older people are more vulnerable to the effects
of substances than younger adults, both physically
and psychologically. They are more at risk from
chronic alcohol related health problems and at
risk from acute problems such as falls.
– They are also more likely to have co-morbid conditions which
increase their risk of harm from alcohol use, such as diabetes,
heart disease, liver disease.
– They may also be on medications which interact negatively with
alcohol.
– See Physical and psychological harms – chronic for more on this.

15. Screening vulnerable groups (cont.)
People from minority ethnic backgrounds
– A concern here is that assessment
using language-based screening tools
may not be appropriate for people
whose first language is not English.
– It is recommended that practitioners
use professional judgement to
determine the most appropriate
approach to screening for these
population groups.

16. Screening vulnerable groups (cont.)
People with learning disability
– Similar concerns arise here for people who may not have mental
capacity to consent to assessment, or may have difficulty
understanding assessment tool questions.
– Again, recommendations are for professional
judgement to be made regarding the most
appropriate approach to screening for people
with a learning disability.

17. Assessment tools for established
alcohol harm
• The following are the tools recommended by NICE for assessing
risky use once harm has been established.
• These may be used by more specialist practitioners or where a more
detailed assessment is necessary. This need indicates a need for
referral or consultation with specialist colleagues.
• Severity of Alcohol Dependence Questionnaire (SADQ) or Leeds
Dependence Questionnaire (LDQ) for severity of dependence
• Clinical Institute Withdrawal Assessment of Alcohol Scale, revised
(CIWA-Ar) for severity of withdrawal .
• Alcohol Problems Questionnaire (APQ) for the nature and extent of
the problems arising from alcohol misuse.

18. References
• Babor, T., Higgins-Biddle, J., Saunders, J., Monteiro, M. (2001) The Alcohol Use
Disorders Identification Test Guidelines for Use in Primary Care. World Health
Organization.
• Department of Health (2016) UK Chief Medical Officers’ Alcohol Guidelines Review.
Summary of the proposed new guidelines. Available online at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/489795
/summary.pdf
• NHS Choices (2015) Alcohol Units. Available at:
http://www.nhs.uk/Livewell/alcohol/Pages/alcohol-units.aspx#table
• NHS Health Scotland (2015) Delivering an ABI: Process, screening tools and
guidance notes. Edinburgh, NHS Health Scotland.
• NICE (2010) Alcohol-use disorders: preventing harmful drinking. National Institute of
Clinical Excellence Public Health Guidance 24.