This manual describes a screening procedure called AUDIT, the Alcohol Use disorders Identification

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WHO/PSA/92.4Original: ENGLISHREVISIONDISTR.: GENERALPROGRAMME ONSUBSTANCEABUSEAUDITThe Alcohol UseDisordersIdentification Test:Guidelines for use inPrimary Health CareThomas F. BaborJuan Ramon de la FuenteJohn SaundersMarcus GrantWORLD HEALTH ORGANIZATIONWHO/PSA/92.4Original: ENGLISHREVISIONDISTR.: GENERALPROGRAMME ONSUBSTANCEABUSEAUDITThe Alcohol UseDisordersIdentification Test:Guidelines for use inPrimary Health CareThomas F. BaborJuan Ramon de la FuenteJohn SaundersMarcus GrantWORLD HEALTH ORGANIZATIONThis manual describes a screening procedure called AUDIT, the Alcohol Use DisordersIdentification Test. The AUDIT procedure was developed by the World HealthOrganization to identify persons whose alcohol consumption has become hazardous orharmful to their health. Because alcohol use poses health risks and causes a variety ofhealth problems, systematic screening by health care workers is likely to contribute topreventive medicine. By way of introducing AUDIT, this manual describes:- the advantages of screening for alcohol problems;- how AUDIT was developed;- applications of AUDIT to the early identification of alcohol-related problems;- scoring and interpretation of AUDIT.U World Health Organization, 1992This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by theOrganization. The document may, however, be freely reviewed, abstracted, reproduced and translated ...

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• Publié par: Difef
• Nombre de lectures: 15
• Langue: English

Extrait

PROGRAMME ON SUBSTANCE ABUSE

AUDIT The Alcohol Use Disorders Identification Test:

Guidelines for use in Primary Health Care

Thomas F. Babor Juan Ramon de la Fuente John Saunders Marcus Grant

WHO/PSA/92.4 Original: ENGLISH REVISION DISTR.: GENERAL

WORLD HEALTH ORGANIZATION

PROGRAMME ON SUBSTANCE ABUSE

AUDIT The Alcohol Use Disorders Identification Test:

Guidelines for use in Primary Health Care

Thomas F. Babor Juan Ramon de la Fuente John Saunders Marcus Grant

WHO/PSA/92.4 Original: ENGLISH REVISION DISTR.: GENERAL

WORLD HEALTH ORGANIZATION

This manual describes a screening procedure called AUDIT, the Alcohol Use Disorders Identification Test. The AUDIT procedure was developed by the World Health Organization to identify persons whose alcohol consumption has become hazardous or harmful to their health. Because alcohol use poses health risks and causes a variety of health problems, systematic screening by health care workers is likely to contribute to preventive medicine. By way of introducing AUDIT, this manual describes: - the advantages of screening for alcohol problems; - how AUDIT was developed; - applications of AUDIT to the early identification of alcohol-related problems; - scoring and interpretation of AUDIT.

U World Health Organization, 1992 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole but not for sale nor for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors.

TABLE OF CONTENTS

 Page Purpose of this Manual .................................................................................................... 1 Benefits of Screening ....................................................................................................... 1 Advances in Screening ..................................................................................................... 1 Development of AUDIT .................................................................................................. 5 How to use AUDIT .......................................................................................................... 8 Scoring and Interpretation of AUDIT .............................................................................. 11 Diagnosis, Management and Referral .............................................................................. 11 References ........................................................................................................................ 17

Appendix A: Research Guidelines for AUDIT ............................................................... 19 Appendix B: Validity of AUDIT and Clinical Screening Procedure .............................. 21 Appendix C: Physical Examination for Clinical Screening Procedure ........................... 23 Appendix D: Note on Translation and Adaptation to Local Drinking Customs .............. 25 Appendix E: Availability of Training Materials for AUDIT ........................................... 27 Appendix F: AUDIT – A Screening Test for Primary Health Care ................................ 29

This is an update of Document No. WHO/MNH/DAT/89.4, under the same

WHO/PSA/92.4 page 1

PURPOSE OF THIS MANUAL This manual describes a screening procedure called AUDIT, theAlcoholUseDisordersIdentificationTest. The AUDIT procedure was developed by the World Health Organization to identify persons whose alcohol consumption has become hazardous or harmful to their health. Because alcohol use poses health risks and causes a variety of health problems, systematic screening by health care workers is likely to contribute to preventive medicine. By way of introducing AUDIT, this manual describes: ?The advantages of screening for alcohol problems; ?How AUDIT was developed; ?Applications of AUDIT to the early identification of alcohol-related problems; ?Scoring and interpretation of AUDIT. Epidemiologists and other health scientists may also wish to use this manual to guide their efforts at further evaluation of this screening instrument. Because the AUDIT procedure is still under development, further research on its reliability and validity is suggested using the guidelines outlined in Appendix A.

THE BENEFITS OF SCREENING Screening is a way of conducting a health examination by using only a portion of the usual diagnostic procedure. It is most often directed at people who appear not to have the condition (e.g., alcohol dependence) in order to identify those who probably have the condition. Alcohol screening tests have often been used for case- finding, that is, identifying persons who are already showing serious alcohol problems. The purpose of AUDIT is to give primary emphasis to screening, not case-finding. The benefits of routine screening include 1. educating drinkers about the hazards of heavy drinking; 2. identifying problems before serious dependence has developed; 3. motivating patients to change their drinking behaviour; and 4. exposing persons at risk to brief but effective interventions that are designed for health care workers (1). Figure 1 shows the large variety of health problems associated with alcohol use. Although these consequences tend to be concentrated in chronic alcoholics, even the use of alcohol in the range of 20-40 grams absolute alcohol per day is a risk factor for accidents, injuries and chronic health conditions (2). This is confirmed by evidence from hospital and primary care settings showing that a significant proportion of general medical patients have alcohol-related problems associated with their presenting symptoms (3). There is general agreement that health care workers are likely to encounter many individuals drinking at harmful or hazardous levels. Because low intensity, brief interventions such as education brochures and sympathetic counselling have much to recommend as the first approach to the harmful drinker (1), primary care workers should play a more active role in screening and early management of harmful alcohol use.

ADVANCES IN SCREENING A screening procedure is a method used to screen for alcohol use, alcohol-related problems, or alcohol dependence. Three types of screening procedure have been used: verbal report methods, such as questionnaires and interviews; biological measures of biochemical and hematological markers; and clinical examination procedures. A variety of screening tests or instruments have been developed using one or several of these procedures.

WHO/PSA/92.4 page 2 Figure 1

EFFECTS OF ALCOHOL ON THE BODY

• high blood pressure •   irregular pulse •   enlarged heart

•  infections including T.B. •   severe swelling and pain •   inflammed liver (hepatitis) •   cirrhosis •   liver cancer •   lining becomes inflamed •   bleeding •   ulcers

• loss of memory •   confusion •   sontinaicullah •   fits

• weakness •   loss of muscle tissue

•  tingling and loss of sensation in hands and feet.

• impotence •   shrinking of testicles •   damage to unborn child (foetus)

•  changes in red blood cells •   flushing •   sweating •   bleeding •   painful inflammation •   inflammation •   bleeding

The Risks of heavy drinking. REPEATED EXCESSIVE DRINKING WILL EVENTUALLY DAMAGE ALL THESE PARTS OF THE BODY

WHO/PSA/92.4 page 3 Recent reviews of alcohol screening (4,5) indicate that certain social and behavioural changes, such as heavy regular consumption, frequent intoxication, concern expressed by others about one’s drinking, and alcohol-related accidents, may be early signs of problem drinking and unambiguous signs of dependence risk. These can be assessed easily by means of interviews or self-administered questionnaires, when the patient does not feel threatened and sees it in his or her best interests to respond accurately. Several laboratory tests may also be useful in the detection of heavy or problematic alcohol use. Serum gamma-glutamyl transferase (GGT), mean corpuscular volume (MCV) of red blood cells and serum aspartate amino transferase (AST) are common laboratory tests likely to provide, at relatively low cost, a possible indication of recent excessive alcohol consumption, especially when used in combination with psychosocial indicators (4). Finally, clinicians have for some time emphasized the importance of physical stigmata in the detection of harmful alcohol use (5). These include tremor of the hands, the appearance of blood vessels in the face, and changes observed in the mucous membranes (e.g., conjunctivitis) and oral cavity (e.g., glossitis). Although no single screening procedure has gained widespread acceptance, each has its own merits, particularly when used in combination with others, or when employed under suitable conditions. Laboratory tests and clinical examination are useful when the patient drinks too much but is unwilling to admit it. Self-report procedures, on the other hand, are rapid, non-invasive, inexpensive, and more comprehensive. They depend on the truthfulness of the patient, but explaining the benefits of providing this information often motivates the patient to answer accurately. The settings in which screening of high risk individuals might be conducted will vary from country to country.Table 1summarizes information about the settings, screening personnel and target groups considered appropriate for a screening programme using AUDIT. Murray (6) has argued that screening might be conducted profitably with: 1. general hospital patients, especially those with disorders known to be associated with alcohol dependence (e.g., pancreatitis, cirrhosis, gastritis, tuberculosis, neurological disorders, cardiomyopathy); 2. persons who attempt suicide; 3. psychiatric patients; 4. patients attending casualty and emergency services; 5. patients attending general practitioners; 6. vagrants; 7. prisoners; 8. those cited for legal offences connected with drinking (e.g., driving while intoxicated, public intoxication). To these should be added groups considered by a recent WHO Expert Committee (7) to be at high risk of developing alcohol-related problems: middle-aged males, adolescents, migrant workers, and certain occupational groups (such as business executives, members of the professions, publicans and seamen). The nature of the risk differs by age, gender, drinking context and drinking pattern, with sociocultural factors playing an important role in the definition and expression of alcohol problems. In general, the design of a screening programme will depend on a variety of considerations that will differ according to the purpose of screening, the groups to be identified, the resources available to the screening agent, and the level of cooperation to be expected from the population screened. When those involved are cooperative and non-defensive about their drinking behaviour, then alcohol-specific verbal report procedures have many advantages. These are particularly useful if embedded in a medical history or lifestyle questionnaire. When the population is suspected of being defensive or forgetful (e.g., the elderly), then laboratory or clinical examination findings may provide important supplementary information. In most cases, a combination of procedures will increase the confidence that can be placed in the results of any given screening test.

WHO/PSA/92.4 page 4

Table 1

Personnel, settings and groups considered appropriate for a screening programme using AUDIT Screener Setting Group Nurse, social workers Primary care clinic Medical patients

Physician, nurse

General practitioner, family  physician

Internist

Psychiatrist

Officers, counsellors

Health and human  services workers

Medics

Work supervisor

Emergency room

Physician’s Room Surgery

General Hospital wards Out-patient clinic

Psychiatric hospital

Court, jail, prison

Other health-related facilities

Armed forces

Employee Assistance Programme (industrial setting)

Accident victims,  intoxicated patients,  trauma victims

Medical patients

GI patients, patients with  hypertension, heart disease  neurological disorders

Psychiatric patients,  particularly those  who are suicidal

DWI offenders, violent  criminals

Persons demonstrating im-  paired social, occupational  functioning (e.g. marital  discord, child neglect)

Enlisted men

Workers

WHO/PSA/92.4 page 5

DEVELOPMENT OF AUDIT In 1982 the World Health Organization asked an international group of investigators to develop a simple screening instrument. Its purpose was to identify persons with early alcohol problems using procedures that were suitable for health workers to use in both developing and developed countries. The investigators reviewed a variety of self-report, laboratory and clinical procedures that had been used for this purpose in different countries. They then initiated a cross-national study to select the best features of these various national approaches to screening (9,10). This comparative field study was conducted in six countries (Norway, Australia, Kenya, Bulgaria, Mexico, and the United States of America). The method consisted of selecting items that best distinguished light drinkers from those with harmful drinking. Unlike previous screening tests, the new instrument was intended for the early identification of harmful drinking rather than alcoholism. However, the screening instrument can also detect alcoholism with a high degree of accuracy. One conclusion from this research is that no single procedure or content domain is universally suitable for the early identification of harmful drinkers in every country. By comparing the relative utility of different procedures, however, the study developed two simple screening procedures that fit the needs of specific early identification programmes and populations at risk. The main screening instrument devised from this study is a ten-item questionnaire called “AUDIT”, the Alcohol Use Disorder Identification Test. Only questions that refer specifically to alcohol were selected. As described inTable 2, the core instrument contains three questions on the amount and frequency of drinking, three questions on alcohol dependence and four on problems caused by alcohol, including adverse psychological reactions. All these domains showed high intra-scale reliability across all collaborating centres and correlated highly with alcohol consumption. The questions themselves were selected on the basis of their representativeness, correlation with alcohol consumption, high face validity, and ability to distinguish light drinkers from those with harmful drinking. In certain medical settings and for groups of patients who may be defensive or uncooperative, a disguised screening procedure may be advantageous. Accordingly, a second “Clinical Screening Instrument” was devised. As shown inTable 3, this consists of two questions about traumatic injury, five items on clinical examination, and a blood test, the serum GGT. The clinical screening instrument does not refer directly to problems with alcohol. It is particularly relevant for those situations where alcohol-specific questions cannot be asked in confidence. Additional information about the validity of both instruments is given in Appendix B. As the first screening test designed specifically for use in primary care settings, AUDIT has the following advantages: ?Cross-national standardization: AUDIT was validated on primary health care patients in six countries. While additional evaluation needs to be conducted, at present AUDIT is the only screening test specifically designed for international uses; ?Identifies harmful and hazardous alcohol use; ?Brief, rapid and flexible; ?Designed for primary health care workers; ?Contains a supplementary non-alcohol-specific clinical instrument; ?ICD-10 definitions of alcohol dependence and harmful alcohol use;Consistent with ?Focuses on recent alcohol use.