Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your
nerves or to get rid of a hangover (eye opener)?
Scoring: Item responses on the CAGE are scored 0 for "no"
and 1 for "yes" answers, with a higher score an indication of
alcohol problems. A total score of 2 or greater is considered clinically
significant.
Source: Ewing, 1984.
As mentioned above, the normal cutoff for the CAGE is two positive answers. However, the Consensus Panel recommends that primary care clinicians lower the threshold to one positive answer to cast a wider net and identify more patients who may have substance use disorders.
A number of other screening tools also are available.
Appendix C includes some of the most widely used options to the AUDIT and the CAGE, including the Michigan Alcoholism Screening Test (MAST)
(Selzer, 1971) and the Short MAST (SMAST)
(Selzer et al., 1975).
Have you felt you ought to cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you felt bad or guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning
to steady your nerves or to get rid of a hangover (eye-opener)?
Source: Reprinted with permission from the Wisconsin Medical
Journal. Brown, R.L., and Rounds, L.A. Conjoint screening questionnaires
for alcohol and drug abuse. Wisconsin Medical Journal 94:135-140,
1995.
Have close friends or relatives worried or complained about
your drinking in the past year?
E
Eye-opener: Do you sometimes take a drink in the morning when
you first get up?
A
Amnesia: Has a friend or family member ever told you about things
you said or did while you were drinking that you could not remember?
K (C)
Do you sometimes feel the need to cut down on your drinking?
Scoring: A 7-point scale is used to score the test.
The "tolerance" question scores 2 points if a woman reports she
can hold more than five drinks without falling asleep or passing out. A
positive response to the "worry" question scores 2 points, and
a positive response to the last three questions scores 1 point each. A
total score of 2 or more indicates the woman is likely to be a risk drinker.
Chlordiazepoxide 25-50 mg p.o. q. 1 h p.r.n. tremulousness, increasing
blood pressure, increased pulse rate, or severe diaphoresis x 5 days.
If patient is vomiting, hold chlordiazepoxide and give instead lorazepam
2 mg IM q. 1 h. p.r.n. tremulousness, increasing blood pressure, or diaphoresis.
Ambien 10 mg at h.s. p.r.n. insomnia. May repeat x 1 during night,
x 5 days.
Thiamine 100 mg q.d.
Multivitamin q.d.
Folic acid 1 mg q.d.
Maalox two tablespoons q. 2 h. p.r.n.
Temperature, pulse, and blood pressure q. 4 h. while awake.
Confine patient to unit until detoxification completed.
Figure 3-1 Interview Approaches that Account for the Patient's Readiness for Behavioral Change
Permission could not be obtained for electronic reproduction. Please
consult the source or a hard copy of this TIP (24) to obtain a copy of Figure 3-1.
Source:Samet et al., 1996. Reproduced with permission
from Archives of Internal Medicine 156:2287-2293, 1996. Copyright 1996,
American Medical Association.
The DSM-IV defines the diagnostic criteria for substance abuse as a
maladaptive pattern of substance use leading to clinically significant
impairment or distress, as manifested by one or more of the following,
occurring within a 12-month period:
Recurrent substance use resulting in a failure to fulfill major role
obligations at work, school, or home (e.g., repeated absences or poor work
performance related to substance use; substance-related absences, suspensions,
or expulsions from school; neglect of children or household).
Recurrent substance use in situations in which it is physically hazardous
(e.g., driving an automobile or operating a machine when impaired by substance
use).
Recurrent substance-related legal problems (e.g., arrests for substance-related
disorderly conduct).
Continued substance use despite having persistent or recurrent social
or interpersonal problems caused or exacerbated by the effects of the substance
(e.g., arguments with spouse about consequences of intoxication, physical
fights).
Source: Reprinted with permission from the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition Copyright 1994, American Psychiatric Association. http://www.appi.org
The DSM-IV defines the diagnostic criteria for substance dependence
as a maladaptive pattern of substance use, leading to clinically significant
impairment or distress, as manifested by three or more of the following,
occurring at any time in the same 12-month period:
Tolerance, as defined by either of the following:
The need for markedly increased amounts of the substance to achieve
intoxication or desired effect.
Markedly diminished effect with continued use of the same amount of
the substance
Withdrawal, as manifested by either of the following:
The characteristic withdrawal syndrome for the substance
The same (or closely related) substance is taken to relieve or avoid
withdrawal symptoms
Taking the substance often in larger amounts or over a longer period
than was intended.
A persistent desire or unsuccessful efforts to cut down or control
substance use.
Spending a great deal of time in activities necessary to obtain or
use the substance or to recover from its effects.
Giving up social, occupational, or recreational activities because
of substance abuse.
Continuing the substance use with the knowledge that it is causing
or exacerbating a persistent or recurrent physical or psychological problem.
Source: Reprinted with permission from the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition Copyright 1994,
American Psychiatric Association.
http://www.appi.org
Hour 1: The first hour is a didactic session focused on screening,
assessment, brief intervention, and referral for alcohol use that includes
role-playing and practice-reinforcing strategies. Participants are sent
out at the end to practice their new skills in "real-world" settings
by using the CAGE questionnaire, for example, and by counseling and referring
patients as needed.
Hour 2: Participants debrief and discuss how they used or did not use their
skills and knowledge. Trainers address any problems encountered and lead
role plays on problem situations. At the end, participants again are instructed
to apply new knowledge and skills in their practice settings.
Hour 3: In this session, discussion focuses on ways to implement changes
in participants' primary care settings to support alcohol and drug screening
and assessment. Particular barriers are identified as well as key persons
to include in change strategies.
Hour 4: This primarily didactic session on pharmacotherapy of alcohol use
disorders focuses on withdrawal, use of disulfiram and naltrexone, and
antidepressants and anxiolytics. The session includes case presentations
and peer discussion.
Hour 5: This primarily didactic session on illicit drugs describes effects
of various drugs of abuse and treatments for drug use disorders. The session
includes case presentations and peer discussion.
Hour 6: This primarily didactic session, including case presentations and
peer discussion, focuses on abuse of prescription drugs and on polypharmacy
among elderly persons.
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