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AUDIT-C Frequently Asked Questions

  1. What is Alcohol Misuse (aka "Unhealthy" Alcohol use)?
  2. Why screen for alcohol misuse?
  3. What is the AUDIT-C?
  4. Who is qualified to perform alcohol screening?
  5. What are recommended drinking limits?
  6. What does a positive AUDIT-C score (>4 for men, >3 for women) mean?
  7. What is a Brief Alcohol Intervention for alcohol misuse?
  8. What should a provider do when a patient screens positive for alcohol misuse or unhealthy drinking?
  9. Why does the VA only require counseling for patients with AUDIT-C scores >5, when scores of >4 for men (>3 for women) are positive screens?
  10. Why do patients who have only one drink a day have a positive AUDIT-C score?
  11. Why is the AUDIT-C cut-off higher for men than women?
  12. What common medical and psychiatric problems are linked to alcohol use?
  13. Does everyone who screens positive on the AUDIT-C need a full assessment or referral?
  14. How can I quickly assess if patients are having symptoms due to drinking?
  15. If a patient screens positive on the AUDIT-C, are they alcohol dependent?
  16. How can I tell if a patient has alcohol dependence?
  17. Will the AUDIT-C miss alcohol dependence?
  18. Why don't we use the CAGE anymore?
  19. How should we manage patients with high AUDIT-C scores (> 8) who are not interested in changing their drinking?
  20. What can I do if a patient doesn't respond after Brief Alcohol Intervention?
  21. Who should be offered referral for further assessment or treatment for alcohol use disorders?
  22. If a patient with likely alcohol dependence refuses referral, what else helps?
  23. What can I do if a patient's AUDIT-C score was high because they were a heavy drinker in the past year but now are no longer drinking?
  24. Why counsel patients who have been treated for alcohol use disorders in the past year?
  25. Are there medications that can help patients cut down or abstain?
  26. What are the AUDIT Questions 4-10?

Screening and Counseling for Alcohol Misuse


1. What is Alcohol Misuse (aka "Unhealthy" Alcohol use)?

Alcohol misuse includes the spectrum from drinking above recommended limits (so called "risky drinking") to severe alcohol dependence. Most patients with alcohol misuse are not alcohol dependent. However, there are so many of these non-dependent patients with unhealthy drinking that they account for most of the morbidity and mortality that is attributed to drinking.1 The term "alcohol misuse" is synonymous with "unhealthy drinking."2

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2. Why screen for alcohol misuse?

Screening for alcohol misuse identifies patients who may benefit from brief alcohol counseling interventions offered by general medical or mental health providers and/or referral to addictions specialists for select patients. Alcohol screening followed by brief alcohol counseling interventions for patients who screen positive decreases drinking,3, 4 and was identified as the 3rd highest prevention priority for US adults, from among all preventive activities recommended by the US Preventive Services Task Force.5

The VA uses a validated brief alcohol screening questionnaire called the AUDIT-C.

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3. What is the AUDIT-C?

The AUDIT-C is a 3 question screen that can help identify patients with alcohol misuse. The AUDIT-C is scored on a scale of 0-12 points (scores of 0 reflect no alcohol use in the past year). In men, a score of 4 points or more is considered positive for alcohol misuse; in women, a score of 3 points or more is considered positive. Generally, the higher the AUDIT-C score, the more likely it is that the patient's drinking is affecting his/her health and safety.

The VA's performance measure requires brief counseling for alcohol use for any patient who scores 5 points or more on the AUDIT-C. The AUDIT-C questions are:

Q#1: How often did you have a drink containing alcohol in the past year?

  • Never (0 points)*
  • Monthly or less (1 point)
  • Two to four times a month (2 points)
  • Two to three times per week (3 points)
  • Four or more times a week (4 points)

Q#2: How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?

  • 0 drinks (0 points)*
  • 1 or 2 (0 points)
  • 3 or 4 (1 point)
  • 5 or 6 (2 points)
  • 7 to 9 (3 points)
  • 10 or more (4 points)

Q#3: How often did you have six or more drinks on one occasion in the past year?

  • Never (0 points)
  • Less than monthly (1 point)
  • Monthly (2 points)
  • Weekly (3 points)
  • Daily or almost daily (4 points)
* If patients are screened by interview, and AUDIT-C question #1 is answered "never", scores of 0 can be validly imputed for questions 2-3.6 If the AUDIT-C is administered on paper or online without a skip pattern (for non drinkers to skip questions #2-3), a "0 drinks" option is typically added to question #2.7

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4. Who is qualified to perform alcohol screening?

Any trained person who is willing to ask the AUDIT-C questions in a private setting, verbatim, and in a nonjudgmental fashion may perform alcohol screening. Many sites find training Medical Assistants or LPN's the most cost effective way to do screening.

Adding an introduction may increase the accuracy of reporting, such as: "Now I am going to ask you some questions about your use of alcohol during the past year. Alcohol use can affect many areas of health and may interfere with certain medications, so it is important for us to know how much you usually drink."8

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5. What are recommended drinking limits?

Recommended limits for alcohol intake have been established by the National Institutes for Health (NIH) based on a large number of epidemiologic studies. People who drink above these limits are at higher risk of alcohol-related problems. These limits serve as a guide, but specific advice is dependent on the patient's overall health. People should not drink at all if they have medical contraindications (such as a prior diagnosis of alcohol dependence, pregnancy or plans to conceive, or medications that interact with alcohol or liver disease).

Recommended limits:

Men: No more than 14 drinks a week, and no more than 4 drinks per occasion

Women: No more than 7 drinks a week, and no more than 3 drinks per occasion

1 drink = 1 standard US drink size:

12 ounces of beer         5 ounces of wine

1.5 oz of hard liquor          8 ounces of malt liquor

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6. What does a positive AUDIT-C score (>4 for men, >3 for women) mean?

A positive score means the patient is probably drinking at unhealthy levels. Some patients with positive scores drink at "risky" levels (levels associated with future adverse consequences), but others meet criteria for alcohol abuse or dependence. The higher the AUDIT-C score, the greater the health risks (Table 3). Table 1 below outlines some specific health risks according to AUDIT-C score.

Table 1 outlines some specific health risks according to AUDIT-C score

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7. What is a Brief Alcohol Intervention for alcohol misuse?

Below are the most common components of brief interventions/counseling that have been shown to decrease drinking:

1) Expressed concern from the provider, regarding unhealthy alcohol use
2) Feedback linking the patient's drinking to his/her health issues
3) Education about recommended drinking limits
4) Offer of explicit advice to cut down drinking or abstain
5) Follow-up 2-4 weeks later to assess the patient's response
6) Referral to specialty addictions treatment if indicated

The most effective interventions are explicitly patient centered and non-confrontational. Asking the patients' permission to discuss, eliciting their thoughts, and using reflection are several methods recommended for engaging patients in behavior change.

Longer counseling sessions are not necessarily better.4 Five minutes of advice has been shown to be as effective as 20 minutes.13

Motivational counseling may also be helpful. An algorithm for motivational counseling is included in an article in the Journal of General Internal Medicine.14

Repeated brief interventions over the phone have been shown to decrease drinking at 3 months among patients with alcohol use disorders (alcohol abuse or dependence).15

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8. What should a provider do when a patient screens positive for alcohol misuse or unhealthy drinking?

Patients in a general medical or mental health setting who screen positive for alcohol misuse or unhealthy drinking should receive 5-15 minutes of brief counseling (i.e. a brief alcohol intervention) about their drinking. Risk of alcohol dependence increases as AUDIT-C scores increase. Patients with a prior history of alcohol treatment or AA are at especially high risk for alcohol dependence and should be considered for further assessment and/or offered referral to a substance use treatment program.

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9. Why does the VA only require follow-up counseling for patients with AUDIT-C scores > 5, when AUDIT-C scores of > 4 for men (> 3 for women) are positive screens?

In some settings the burden or cost of counseling patients with false positive screens, relative to the benefit screening and brief counseling, is high enough that health care systems may choose to use a higher cut point. Therefore, the VA has elected to require follow up for its performance measure for brief alcohol counseling at the threshold of 5 to minimize the burden of false positives screens on providers. This also helps focus providers' attention on the patients with more severe alcohol misuse.6, 16

The sensitivity and specificity for identifying patients with alcohol misuse (risky drinking, alcohol abuse or dependence) with a score of 5 or more in comparison with other thresholds are shown below.

Table 2: Sensitivity and Specificity of the AUDIT-C for Identification of Patients with Risky Drinking and/or Active-DSM Alcohol Abuse or Dependence

Sensitivity: the ability of the test to identify correctly those who have the condition; a test with high sensitivity has few false negatives.

Specificity: the ability of the test to identify correctly those who do not have the condition; a test with high specificity has few false positives.

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10. Why do patients who have only one drink a day screen positive on the AUDIT-C?

The screening thresholds that balance sensitivity and specificity are based on studies that used in-depth interviews to assess patients' drinking and problems due to drinking. These studies found that scores of 4 or more for men and 3 or more for women were optimal for identifying those with risky drinking or active alcohol use disorders, probably because patients often under-report their drinking.7, 16 However, like all screening tests, the AUDIT-C will have some false positives and some false negatives.

Patients with positive AUDIT-C screens at scores of 3 for women or 4 for men might benefit from further assessment and/or intervention. This can be addressed in several ways, such as:

  • Review alcohol intake over the past few months to confirm accuracy, including details of intake for each day in the past week to determine whether typical drinking is within recommended limits. Ask the patient: Has this been your consistent pattern over the past 2-3 months?
  • Review the patient's medical history and medication list for contraindications to drinking.
    • Ask if the patient has a history of hepatitis C, prior alcohol treatment, prior alcohol or substance use disorder diagnosis, is attempting to conceive, or is pregnant.
  • Counsel patients to cut down if they exceed recommended limits, and educate them about the link between alcohol use and health.
    • Communicate recommended limits and counsel patient to always drink below those limits. Make sure to define standard drink sizes.

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11. Why is the AUDIT-C cut-off higher for men than women?

The recommended cut-off for women is based on studies of women (VA and non-VA), which used in-depth interviews to assess their drinking patterns and problems due to drinking.6, 7, 16, 17 Both VA and Non VA Women develop problems due to drinking at lower levels of alcohol consumption than men (e.g. breast cancer and liver disease). This reflects their lower total body water as well as possible differences in metabolism and susceptibility to disease. Alcohol use is also more stigmatized for women compared to men, so women may be more likely to under-report their drinking.

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12. What common medical and psychiatric problems are linked to alcohol use?

Alcohol misuse has been linked to the following medical and psychiatric problems:

  • Depression, post traumatic stress disorder (PTSD), insomnia, injuries
  • Hypertension, obesity, congestive heart failure (CHF), liver disease, stroke
  • Breast cancer, pancreas cancer
  • Reflux (GERD), upper gastrointestinal (GI) bleed

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13. Does everyone who screens positive on the AUDIT-C need a full assessment or referral?

Not everyone needs a full diagnostic assessment or referral. Since the AUDIT-C score reflects severity, the raw score can be used to assess the likelihood that the patient has alcohol dependence. For patients with AUDIT-C scores 4-7 (3-7 for women) and no prior alcohol treatment, the provider can offer a brief alcohol intervention, and follow-up to evaluate how the patient responds (as the first step). If patients do not respond, further assessment may be helpful to identify alcohol abuse and dependence, other substance use disorders, and unrecognized psychiatric comorbidity.

Patients with a history of alcohol treatment and higher AUDIT-C scores will often have alcohol dependence. Patients with AUDIT-C scores of 8 or more have been shown to be at increased risk for many complications of drinking and should be more fully assessed if possible and offered referral as appropriate.

If providers want to assess patients for specific symptoms due to drinking, questions #4-10 of the full AUDIT can be used as a brief assessment. Further assessment tools are also available in the NIAAA Clinician's Guide for symptoms of alcohol abuse and dependence, or patients can be referred to a mental health specialist.

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14. How can I quickly assess if patients are having symptoms due to drinking?

Screen the patient with questions 4-10 of the 10 item AUDIT (World Health Organization) to identify symptoms due to drinking. Total scores of 8 or more are recommended as indicators of hazardous and harmful alcohol use, as well as possible alcohol dependence. Click here (172 KB, PDF) for more information about the AUDIT and scoring.

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15. If a patient screens positive on the AUDIT-C, is it likely they are alcohol dependent?

Most patients who screen positive on the AUDIT-C drink at risky levels, but are not alcohol dependent. By using both the AUDIT-C score and the patient's history of alcohol treatment, it is possible to identify those most likely to be dependent. For patients who have never been in alcohol treatment (or attended AA), scores > 8 are associated with relatively high rates of dependence. Patients who have had past alcohol treatment are at high risk of dependence with any positive AUDIT-C score. Among VA outpatients who screen positive for alcohol misuse with an AUDIT score > 5, 19% (among positives) have documentation of prior addictions treatment or previously recognized AUD.

Increasing AUDIT-C scores are associated with increasing risk of alcohol dependence. Based on a large non-VA primary care sample, the probability of alcohol dependence of men and women with different AUDIT-C scores are shown in the table below.18

Table 3: Probability of Alcohol Dependence for Men and Women by AUDIT-C Scores

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16. How can I tell if a patient has alcohol dependence?

There are 7 criteria for alcohol dependence used by Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), Revised.

  1. Tolerance: need to drink more to get same effect
  2. Withdrawal or morning drinking
  3. Impaired control: drink more or longer than intended
  4. Unable to cut down
  5. Large amount of time spent drinking or recovering from drinking
  6. Neglect other responsibilities or activities
  7. Continued use despite acknowledgement of problems caused by drinking

To meet criteria for DSM-IV alcohol dependence a patient must have 3 of these symptoms in a 12 month period. However, increasingly, alcohol dependence is thought of as a spectrum with frequent drinking of > 5 drinks for men and > 4 for women per occasion an early symptom of dependence. Experts are considering including the frequency of drinking at these levels in DSM-IV criteria for alcohol dependence.19

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17. Will the AUDIT-C miss alcohol dependence?

Any self-reported screening test will fail to identify the target condition for some patients who do not provide candid responses. In validation studies that compared the AUDIT-C to in-depth interviews, the AUDIT-C performed as well as the CAGE Questionnaire for identifying male patients with active alcohol abuse or dependence.7, 20 It was also an effective screening test for active alcohol abuse or dependence in women16 and more effective than the TWEAK (an adaptation of the CAGE for women).21

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18. Why don't we use the CAGE anymore?

The CAGE identifies patients with alcohol abuse or dependence at any time in their lives, but many patients with risky drinking are NOT identified by the CAGE.20 It is important to identify patients with nondependent risky drinking because they may benefit from brief counseling about their drinking from primary care or general mental health providers.22

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19. How should we manage patients with high AUDIT-C scores (> 8) who are not interested in changing their drinking?

Addressing issues for which the patient is seeking medical care and linking those issues to alcohol use, when possible, can help engage patients regarding changing their drinking. Addressing the patient's social needs (housing, food) may make them more likely to engage in alcohol treatment. Repeated visits with feedback on blood pressure, lab values if elevated (e.g. SGGT monthly or MCV Q4 months), or other symptoms provide patients with positive feedback on the benefits of any decreases in drinking and can help motivate some patients to change.23

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20. What can I do if a patient doesn't respond after Brief Alcohol Intervention?

Patients who are unable to cut down their alcohol consumption or abstain should be offered referral to an addictions treatment program.

For patients who decline treatment, even if they are alcohol dependent, there is evidence that repeated brief interventions (BI) are effective. The content of the BI should continue to include explicit advice to decrease drinking or abstain, and may also be focused on how the increased alcohol use impacts the patient's health.

These repeated BI's may be done during an office visit, or over the phone. A randomized controlled trial of telephone follow up for brief intervention demonstrated that male patients who engaged in 6 calls (using motivational interview techniques) reported significantly cutting down their drinking at 3 months compared with the control group.15

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21. Who should be offered referral for further assessment or treatment for alcohol use disorders?

Patients who screen positive for alcohol misuse (AUDIT-C > 5) or drink despite medical contraindications* should be offered referral to specialty substance use disorder (SUD) care for addiction treatment if the patient:

  • May benefit from additional evaluation of his/her drinking or substance use and related problems or from motivational interviewing
  • Has tried and been unable to change drinking or substance use on his/her own or does not respond to brief intervention
  • Has been diagnosed for alcohol or other substance dependence
  • Has previously been treated for an alcohol or other substance use disorders
  • Has an AUDIT-C score > 8.

*Medical contraindications to drinking include (but are not limited to) medications that interact with alcohol, hepatitis, cirrhosis, pregnancy or trying to conceive.

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22. If a patient with likely alcohol dependence refuses referral, what else could help?

Repeated brief intervention, either during clinic visits or follow-up telephone calls, can be effective. Patients with alcohol abuse and dependence should also be encouraged to join Alcoholics Anonymous (AA).24 Many patients are helped to maintain abstinence by attending AA. Other strategies that can help patients cut down are included in the NIAAA Clinician's Guide and NIAAA "Rethinking Drinking" pamphlet for patients.

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23. What can I do if a patient's AUDIT-C score was high because they were a heavy drinker in the past year but now are no longer drinking?

Patients who stop heavy drinking are at high risk for relapse and their providers should monitor their alcohol use carefully. These patients should be encouraged to maintain healthy changes with explicit advice to continue to abstain, or at minimum, to drink below recommended limits.

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24. Why counsel patients who have been treated for alcohol use disorders in the past year?

Patients who score positive on the AUDIT-C benefit from counseling even if they have been in an addictions treatment program because many of these patients will relapse. Relapse in the 12 months after treatment was started is especially common.

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25. Are there medications that can help patients cut down or abstain?

Medications for alcohol dependence approved by the US Food and Drug Administration (FDA) include Disulfuram (Antabuse), Naltrexone and Acamprosate. The NIAAA Clinician's Guide has helpful information for use of these. All three of these medications have been shown to be effective for some patients and can be managed in the primary care setting with support from a primary care-mental health team. In addition, recent trials have shown other medications to be associated with decreased drinking including: Topiramate 25 Baclofen,26 Gabapentin,27, and Prazosin.28 If patients have other indications for these medications, they may also benefit from their potential effect on alcohol dependence.

Patients who are unable or unwilling initially to consider abstinence as a goal might benefit from medications for alcohol dependence. The NIAAA Clinician's Guide and the NIAAA COMBINE Medical Management Treatment Manual list information and contraindications to FDA approved medications. The COMBINE trial suggested that even a placebo and medical management had a significant benefit.29 The number needed to treat (NNT) with Naltrexone to have 1 primary care patient benefit is 6 (Naltrexone), and for specialty treatment is 7.

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26. What are the AUDIT Questions 4-10? (pdf of full AUDIT, 81 KB)

Q#4: How often during the last year have you found that you were not able to stop drinking once you had started?

  • Never (0 points)
  • Less than monthly (1 point)
  • Monthly (2 points)
  • Weekly (3 points)
  • Daily or almost daily (4 points)

5. How often during the last year have you failed to do what was normally expected of you because of drinking?

  • Never (0 points)
  • Less than monthly (1 point)
  • Monthly (2 points)
  • Weekly (3 points)
  • Daily or almost daily (4 points)

6. 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 (0 points)
  • Less than monthly (1 point)
  • Monthly (2 points)
  • Weekly (3 points)
  • Daily or almost daily (4 points)

7. How often during the last year have you had a feeling of guilt or remorse after drinking?

  • Never (0 points)
  • Less than monthly (1 point)
  • Monthly (2 points)
  • Weekly (3 points)
  • Daily or almost daily (4 points)

8. How often during the last year have you been unable to remember what happened the night before because of your drinking?

  • Never (0 points)
  • Less than monthly (1 point)
  • Monthly (2 points)
  • Weekly (3 points)
  • Daily or almost daily (4 points)

9. Have you or someone else been injured because of your drinking?

  • No (0 points)
  • Yes, but not in the last year (2 points)
  • Yes, during the last year (4 points)

10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

  • No (0 points)
  • Yes, but not in the last year (2 points)
  • Yes, during the last year (4 points)

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References

  1. Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems: A Report of the Committee for the Study of Treatment and Rehabilitation for Alcoholism. Washington DC: National Academy Press; 1990.
  2. Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. Feb 10 2005;352(6):596-607.
  3. Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:557-568.
  4. Kaner E, Beyer F, Dickinson H, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007(2):CD004148.
  5. Solberg LI, Maciosek MV, Edwards NM. Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness. Am J Prev Med. Feb 2008;34(2):143-152.
  6. Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res. Jul 2007;31(7):1208-1217.
  7. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. Sep 14 1998;158(16):1789-1795.
  8. Babor TF, de la Fuente JR, Saunders J, Grant M. AUDIT: Alcohol Use Disorders Identification Test: guidelines for use in primary health care: Geneva, World Health Organization; 1989b 1989. WHO/MNH/DAT/89.4.
  9. Bryson CL, Au DH, Sun H, Williams EC, Kivlahan DR, Bradley KA. Alcohol screening scores and medication nonadherence. Ann Intern Med. Dec 2 2008;149(11):795-804.
  10. Au DH, Kivlahan DR, Bryson CL, Blough D, Bradley KA. Alcohol Screening Scores and Risk of Hospitalizations for GI Conditions in Men. Alcohol Clin Exp Res. Mar 2007;31(3):443-451.
  11. Harris AH, Bryson CL, Sun H, Blough D, Bradley KA. Alcohol Screening Scores Predict Risk of Subsequent Fractures. Subst Use Misuse. Jun 17 2009;44:1055-1069.
  12. Kinder LS, Bryson CL, Sun H, Williams EC, Bradley KA. Alcohol screening scores and all-cause mortality in male Veterans Affairs patients. J Stud Alcohol Drugs. Mar 2009;70(2):253-260.
  13. WHO Brief Intervention Study Group. A cross-national trial of brief interventions with heavy drinkers. Am J Public Health. 1996;86(7):948-955.
  14. Adams A, Okene JK, Wheele EV, Hurley TG. Alcohol counseling - physicians will do it. J Gen Intern Med. 1998;13:692-698.
  15. Brown RL, Saunders LA, Bobula JA, Mundt MP, Koch PE. Randomized-controlled trial of a telephone and mail intervention for alcohol use disorders: three-month drinking outcomes. Alcohol Clin Exp Res. Aug 2007;31(8):1372-1379.
  16. Bradley KA, Bush KR, Epler AJ, et al. Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch Intern Med. Apr 14 2003;163(7):821-829.
  17. Dawson DA, Grant BF, Li TK. Quantifying the risks associated with exceeding recommended drinking limits. Alcohol Clin Exp Res. May 2005;29(5):902-908.
  18. Rubinsky AD, Kivlahan DR, Volk RJ, Maynard C, Bradley KA. Screening for risk of alcohol dependence using stratum-specific likelihood ratios. Drug and Alcohol Dependence. 2009;In press.
  19. Li TK, Hewitt BG, Grant BF. Is there a future for quantifying drinking in the diagnosis, treatment, and prevention of alcohol use disorders? Alcohol Alcohol. Mar-Apr 2007;42(2):57-63.
  20. Bradley KA, Bush KR, McDonell MB, Malone T, Fihn SD. Screening for problem drinking: comparison of CAGE and AUDIT. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. J Gen Intern Med. Jun 1998;13(6):379-388.
  21. Bush KR, Kivlahan DR, Davis TM, et al. The TWEAK is weak for alcohol screening among female Veterans Affairs outpatients. Alcoholism: Clin Exp Res. 2003;27(12):1971-1978.
  22. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices. JAMA. 1997;277(13):1039-1045.
  23. Willenbring ML, Olson DH. A randomized trial of integrated outpatient treatment for medically ill alcoholic men. Arch Intern Med. Sep 13 1999;159(16):1946-1952.
  24. Timko C, Billow R, DeBenedetti A. Determinants of 12-step group affiliation and moderators of the affiliation-abstinence relationship. Drug Alcohol Depend. Jun 28 2006;83(2):111-121.
  25. Johnson BA, Rosenthal N, Capece JA, et al. Topiramate for treating alcohol dependence: a randomized controlled trial. Jama. Oct 10 2007;298(14):1641-1651.
  26. Addolorato G, Leggio L, Ferrulli A, et al. Effectiveness and safety of baclofen for maintenance of alcohol abstinence in alcohol-dependent patients with liver cirrhosis: randomised, double-blind controlled study. Lancet. Dec 8 2007;370(9603):1915-1922.
  27. Myrick H, Malcolm R, Randall PK, et al. A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res. Sep 2009;33(9):1582-1588.
  28. Simpson TL, Saxon AJ, Meredith CW, et al. A Pilot Trial of the Alpha-1 Adrenergic Antagonist, Prazosin, for Alcohol Dependence. Alcohol Clin Exp Res. Oct 21 2008.
  29. Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. May 3 2006;295(17):2003-2017.

Additional questions or more information?
Please contact Carol.Achtmeyer@med.va.gov