Professional Documents
Culture Documents
6a
Original: English
Distribution: General
Thomas F. Babor
John C. Higgins-Biddle
John B. Saunders
Maristela G. Monteiro
AUDIT
Second Edition
Thomas F. Babor
John C. Higgins-Biddle
John B. Saunders
Maristela G. Monteiro
AUDIT
Second Edition
Abstract
This manual introduces the AUDIT, the Alcohol Use Disorders Identification Test, and describes how to
use it to identify persons with hazardous and harmful patterns of alcohol consumption. The AUDIT was
developed by the World Health Organization (WHO) as a simple method of screening for excessive drinking
and to assist in brief assessment. It can help in identifying excessive drinking as the cause of the presenting
illness. It also provides a framework for intervention to help hazardous and harmful drinkers reduce or cease
alcohol consumption and thereby avoid the harmful consequences of their drinking. The first edition of this
manual was published in 1989 (Document No. WHO/MNH/DAT/89.4) and was subsequently updated in
1992 (WHO/PSA/92.4). Since that time it has enjoyed widespread use by both health workers and alcohol
researchers. With the growing use of alcohol screening and the international popularity of the AUDIT,
there was a need to revise the manual to take into account advances in research and clinical experience.
This manual is written primarily for health care practitioners, but other professionals who encounter persons
with alcohol-related problems may also find it useful. It is designed to be used in conjunction with a
companion document that provides complementary information about early intervention procedures, entitled
“Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care”. Together
these manuals describe a comprehensive approach to screening and brief intervention for alcohol-related
problems in primary health care.
Acknowledgements
The revision and finalisation of this document were coordinated by Maristela Monteiro with technical
assistance from Vladimir Poznyak from the WHO Department of Mental Health and Substance Dependence,
and Deborah Talamini, University of Connecticut. Financial support for this publication was provided by
the Ministry of Health and Welfare of Japan.
Table of Contents
14 Administration Guidelines
25 Programme Implementation
Appendix
35 References
4 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
his manual introduces the AUDIT, the The appendices to this manual contain
T Alcohol Use Disorders Identification additional information useful to practi-
Test, and describes how to use it to identify tioners and researchers. Further research
persons with hazardous and harmful pat- on the reliability, validity, and implemen-
terns of alcohol consumption. The AUDIT tation of screening with the AUDIT is
was developed by the World Health suggested using guidelines outlined in
Organization (WHO) as a simple method Appendix A. Appendix B contains an
of screening for excessive drinking and to example of the AUDIT in a self-report
assist in brief assessment.1,2 It can help questionnaire format. Appendix C pro-
identify excessive drinking as the cause vides guidelines for the translation and
of the presenting illness. It provides adaptation of the AUDIT. Appendix D
a framework for intervention to help risky describes clinical screening procedures
drinkers reduce or cease alcohol con- using a physical exam, laboratory tests
sumption and thereby avoid the harmful and medical history data. Appendix E lists
consequences of their drinking. The AUDIT information about available training
also helps to identify alcohol dependence materials.
and some specific consequences of harm-
ful drinking. It is particularly designed for
health care practitioners and a range of
health settings, but with suitable instruc-
tions it can be self-administered or used
by non-health professionals.
here are many forms of excessive Harmful use refers to alcohol consump-
T drinking that cause substantial risk or tion that results in consequences to phys-
harm to the individual. They include high ical and mental health. Some would also
level drinking each day, repeated consider social consequences among the
episodes of drinking to intoxication, harms caused by alcohol3, 4.
drinking that is actually causing physical
or mental harm, and drinking that has Alcohol dependence is a cluster of
resulted in the person becoming depen- behavioural, cognitive, and physiological
dent or addicted to alcohol. Excessive phenomena that may develop after
drinking causes illness and distress to the repeated alcohol use4. Typically, these
drinker and his or her family and friends. phenomena include a strong desire to
It is a major cause of breakdown in rela- consume alcohol, impaired control over
tionships, trauma, hospitalization, pro- its use, persistent drinking despite harm-
longed disability and early death. ful consequences, a higher priority given
Alcohol-related problems represent an to drinking than to other activities and
immense economic loss to many commu- obligations, increased alcohol tolerance,
nities around the world. and a physical withdrawal reaction when
alcohol use is discontinued.
AUDIT was developed to screen for
excessive drinking and in particular to Alcohol is implicated in a wide variety of
help practitioners identify people who diseases, disorders, and injuries, as well as
would benefit from reducing or ceasing many social and legal problems5,6,7. It is a
drinking. The majority of excessive major cause of cancer of the mouth,
drinkers are undiagnosed. Often they esophagus, and larynx. Liver cirrhosis and
present with symptoms or problems that pancreatitis often result from long-term,
would not normally be linked to their excessive consumption. Alcohol causes
drinking. The AUDIT will help the practi- harm to fetuses in women who are preg-
tioner identify whether the person has nant. Moreover, much more common
hazardous (or risky) drinking, harmful medical conditions, such as hypertension,
drinking, or alcohol dependence. gastritis, diabetes, and some forms of
stroke are likely to be aggravated even by
Hazardous drinking 3 is a pattern of alco- occasional and short-term alcohol con-
hol consumption that increases the risk sumption, as are mental disorders such as
of harmful consequences for the user or depression. Automobile and pedestrian
others. Hazardous drinking patterns are injuries, falls, and work-related harm fre-
of public health significance despite the quently result from excessive alcohol con-
absence of any current disorder in the sumption. The risks related to alcohol are
individual user. linked to the pattern of drinking and the
amount of consumption5. While persons
with alcohol
6 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
dependence are most likely to incur high in hazardous alcohol use. Given these
levels of harm, the bulk of harm associat- factors, the need for screening becomes
ed with alcohol occurs among people who apparent.
are not dependent, if only because there
are so many of them8. Therefore, the Screening for alcohol consumption
identification of drinkers with various among patients in primary care carries
types and degrees of at-risk alcohol con- many potential benefits. It provides an
sumption has great potential to reduce all opportunity to educate patients about
types of alcohol-related harm. low-risk consumption levels and the risks
of excessive alcohol use. Information
Figure 1 illustrates the large variety of about the amount and frequency of alco-
health problems associated with alcohol hol consumption may inform the diagno-
use. Although many of these medical sis of the patient’s presenting condition,
consequences tend to be concentrated in and it may alert clinicians to the need to
persons with severe alcohol dependence, advise patients whose alcohol consump-
even the use of alcohol in the range of tion might adversely affect their use of
20-40 grams of absolute alcohol per day medications and other aspects of their
is a risk factor for accidents, injuries, and treatment. Screening also offers the
many social problems5, 6. opportunity for practitioners to take pre-
ventative measures that have proven
Many factors contribute to the develop- effective in reducing alcohol-related risks.
ment of alcohol-related problems.
Ignorance of drinking limits and of the
risks associated with excessive alcohol
consumption are major factors. Social
and environmental influences, such as
customs and attitudes that favor heavy
drinking, also play important roles. Of
utmost importance for screening, however,
is the fact that people who are not
dependent on alcohol may stop or
reduce their alcohol consumption with
appropriate assistance and effort. Once
dependence has developed, cessation
of alcohol consumption is more difficult
and often requires specialized treatment.
Although not all hazardous drinkers
become dependent, no one develops
alcohol dependence without having
engaged for some time
WHY SCREEN FOR ALCOHOL USE? I7
Figure 1
Liver damage.
Vitamin deficiency. Bleeding.
Severe inflammation
of the stomach. Vomiting.
Trembling hands. Diarrhea. Malnutrition.
Tingling fingers.
Numbness. Painful nerves.
Impaired sensation
leading to falls. In men:
Impaired sexual performance.
In women:
Risk of giving birth to deformed,
retarded babies or low birth
weight babies.
High-risk drinking may lead to social, legal, medical, domestic, job and financial
problems. It may also cut your lifespan and lead to accidents and death from drunk-
en driving.
8 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
hile this manual focuses on using the To these should be added groups consid-
W AUDIT to screen for alcohol con- ered by a WHO Expert Committee7 to be
sumption and related risks in primary care at high risk of developing alcohol-related
medical settings, the AUDIT can be effec- problems: middle-aged males, adolescents,
tively applied in many other contexts as migrant workers, and certain occupation-
well. In many cases procedures have al groups (such as business executives,
already been developed and used in these entertainers, sex workers, publicans, and
settings. Box 1 summarizes information seamen). The nature of the risk differs by
about the settings, screening personnel, age, gender, drinking context, and drinking
and target groups considered appropriate pattern, with sociocultural factors playing
for a screening programme using the AUDIT. an important role in the definition and
Murray9 has argued that screening might expression of alcohol-related problems6.
be conducted profitably with:
■ general hospital patients, especially those
with disorders known to be associated
with alcohol dependence (e.g., pancre-
atitis, cirrhosis, gastritis, tuberculosis,
neurological disorders, cardiomyopathy);
■ persons who are depressed or who
attempt suicide;
■ other psychiatric patients;
■ patients attending casualty and emer-
gency services;
■ patients attending general practitioners;
■ vagrants;
■ prisoners; and
■ those cited for legal offences connected
with drinking (e.g., driving while intoxi-
cated, public intoxication).
THE CONTEXT OF ALCOHOL SCREENING I9
Box 1
Development and
Validation of the AUDIT
he AUDIT was developed and evaluat- This comparative field study was conducted
T ed over a period of two decades, and in six countries (Norway, Australia, Kenya,
it has been found to provide an accurate Bulgaria, Mexico, and the United States
measure of risk across gender, age, and of America).
cultures1, 2,10. Box 2 describes the conceptu-
al domains and item content of the AUDIT, The method consisted of selecting items
which consists of 10 questions about that best distinguished low-risk drinkers
recent alcohol use, alcohol dependence from those with harmful drinking. Unlike
symptoms, and alcohol-related problems. previous screening tests, the new instrument
As the first screening test designed specif- was intended for the early identification of
ically for use in primary care settings, the hazardous and harmful drinking as well as
AUDIT has the following advantages: alcohol dependence (alcoholism). Nearly
2000 patients were recruited from a variety
■ Cross-national standardization: the
of health care facilities, including specialized
AUDIT was validated on primary health
alcohol treatment centers. Sixty-four percent
care patients in six countries1,2. It is the
were current drinkers, 25% of whom were
only screening test specifically designed
diagnosed as alcohol dependent.
for international use;
■ Identifies hazardous and harmful alco- Participants were given a physical exami-
hol use, as well as possible dependence; nation, including a blood test for standard
■ Brief, rapid, and flexible; blood markers of alcoholism, as well as an
■ Designed for primary health care workers; extensive interview assessing demographic
characteristics, medical history, health
■ Consistent with ICD-10 definitions of alco-
complaints, use of alcohol and drugs, psy-
hol dependence and harmful alcohol use3,4;
chological reactions to alcohol, problems
■ Focuses on recent alcohol use. associated with drinking, and family histo-
In 1982 the World Health Organization ry of alcohol problems. Items were select-
asked an international group of investiga- ed for the AUDIT from this pool of ques-
tors to develop a simple screening instru- tions primarily on the basis of correlations
ment2. Its purpose was to identify persons with daily alcohol intake, frequency of
with early alcohol problems using proce- consuming six or more drinks per drinking
dures that were suitable for health systems episode, and their ability to discriminate
in both developing and developed countries. hazardous and harmful drinkers. Items were
The investigators reviewed a variety of also chosen on the basis of face validity,
self-report, laboratory, and clinical proce- clinical relevance, and coverage of relevant
dures that had been used for this purpose conceptual domains (i.e., alcohol use, alco-
in different countries. They then initiated a hol dependence, and adverse consequences
cross-national study to select the best fea- of drinking). Finally, special attention in item
tures of these various national approaches selection was given to gender appropriate-
to screening1. ness and cross-national generalizability.
DEVELOPMENT AND VALIDATION OF THE AUDIT I 11
Box 2
Sensitivities and specificities of the select- ment samples1, a cut-off value of 8 points
ed test items were computed for multiple yielded sensitivities for the AUDIT for vari-
criteria (i.e., average daily alcohol consump- ous indices of problematic drinking that
tion, recurrent intoxication, presence of at were generally in the mid 0.90’s.
least one dependence symptom, diagnosis Specificities across countries and across
of alcohol abuse or dependence, and self- criteria averaged in the 0.80’s.
perception of a drinking problem). Various
cut-off points in total scores were consid- The AUDIT differs from other self-report
ered to identify the value with optimal screening tests in that it was based on
sensitivity (percentage of positive cases data collected from a large multinational
that the test correctly identified) and sample, used an explicit conceptual-
specificity (percentage of negative cases statistical rationale for item selection,
that the test correctly identified) to distin- emphasizes identification of hazardous
guish hazardous and harmful alcohol use. drinking rather than long-term dependence
In addition, validity was also computed and adverse drinking consequences, and
against a composite diagnosis of harmful focuses primarily on symptoms occurring
use and dependence. In the test develop- during the recent past rather than “ever.”
12 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Once the AUDIT had been published, the cultures11, 12, 13, 15, 19, 22, 23, 24, suggesting
developers recommended additional vali- that the AUDIT has fulfilled its promise as
dation research. In response to this request, an international screening test.
a large number of studies have been con-
ducted to evaluate its validity and reliabil- Although evidence on women is somewhat
ity in different clinical and community limited11, 12, 24, the AUDIT seems equally
samples throughout the world10. At the appropriate for males and females. The
recommended cut-off of 8, most studies effect of age has not been systematically
have found very favorable sensitivity and analyzed as a possible influence on the
usually lower, but still acceptable, speci- AUDIT, but one study19 found low sensi-
ficity, for current ICD-10 alcohol use dis- tivity but high specificity in patients above
orders10,11,12 as well as the risk of future age 65. The AUDIT has proven to be
harm12. Nevertheless, improvements in accurate in detecting alcohol dependence
detection have been achieved in some in university students18.
cases by lowering or raising the cut-off
score by one or two points, depending In comparison to other screening tests,
on the population and the purpose of the AUDIT has been found to perform
the screening programme11,12. equally well or at a higher degree of accu-
racy10, 11, 25, 26 across a wide variety of cri-
A variety of subpopulations have been stud- terion measures. Bohn, et al.27 found a
ied, including primary care patients 13, 14, 15, strong correlation between the AUDIT
emergency room cases11, drug users16, and the MAST (r=.88) for both males and
the unemployed17, university students18, females, and correlations of .47 and .46
elderly hospital patients19, and persons of for males and females, respectively, on a
low socio-economic status20. The AUDIT covert content alcoholism screening test.
has been found to provide good discrimi- A high correlation coefficient (.78) was
nation in a variety of settings where these also found between the AUDIT and the
populations are encountered. A recent CAGE in ambulatory care patients26.
systematic review21 of the literature has AUDIT scores were found to correlate well
concluded that the AUDIT is the best with measures of drinking consequences,
screening instrument for the whole range attitudes toward drinking, vulnerability to
of alcohol problems in primary care, as alcohol dependence, negative mood states
compared to other questionnaires such as after drinking, and reasons for drinking27.
the CAGE and the MAST. It appears that the total score on the AUDIT
reflects the extent of alcohol involvement
Cultural appropriateness and cross- along a broad continuum of severity.
national applicability were important con-
siderations in the development of the Two studies have considered the relation
AUDIT1, 2. Research has been conducted between AUDIT scores and future indica-
in a wide variety of countries and tors of alcohol-related problems and more
DEVELOPMENT AND VALIDATION OF THE AUDIT I 13
global life functioning. In one study17, the It was concluded that the ER is an ideal
likelihood of remaining unemployed over setting for implementing alcohol screen-
a two year period was 1.6 times higher ing with the AUDIT. Similarly, Piccinelli, et
for individuals with scores of 8 or more al.15 evaluated the AUDIT as a screening
on the AUDIT than for comparable per- tool for hazardous alcohol intake in prima-
sons with lower scores. In another study28, ry care clinics in Italy. AUDIT performed
AUDIT scores of ambulatory care patients well in identifying alcohol-related disorders
predicted future occurrence of a physical as well as hazardous use. Ivis, et al.22
disorder, as well as social problems relat- incorporated the AUDIT into a general
ed to drinking. AUDIT scores also predict- population telephone survey in Ontario,
ed health care utilization and future risk Canada.
of engaging in hazardous drinking28.
Since the AUDIT User’s Manual was first
Several studies have reported on the reli- published in 198930, the test has fulfilled
ability of the AUDIT18, 26, 29. The results many of the expectations that inspired its
indicate high internal consistency, suggest- development. Its reliability and validity have
ing that the AUDIT is measuring a single been established in research conducted in
construct in a reliable fashion. A test-retest a variety of settings and in many different
reliability study29 indicated high reliability nations. It has been translated into many
(r=.86) in a sample consisting of non-haz- languages, including Turkish, Greek, Hindi,
ardous drinkers, cocaine abusers, and German, Dutch, Polish, Japanese, French,
alcoholics. Another methodological study Portuguese, Spanish, Danish, Flemish,
was conducted in part to investigate the Bulgarian, Chinese, Italian, and Nigerian
effect of question ordering and wording dialects. Training programmes have been
changes on prevalence estimates and developed to facilitate its use by physicians
internal consistency reliability22. Changes and other health care providers31, 32 (see
in question ordering and wording did not Appendix E). It has been used in primary
affect the AUDIT scores, suggesting that care research and in epidemiological
within limits, researchers can exercise studies for the estimation of prevalence
some flexibility in modifying the order in the general population as well as spe-
and wording of the AUDIT items. cific institutional groups (e.g., hospital
patients, primary care patients). Despite
With increasing evidence of the reliability the high level of research activity on the
and validity of the AUDIT, studies have AUDIT, further research is needed, espe-
been conducted using the test as a cially in the less developed countries.
prevalence measure. Lapham, et al.23 Appendix A provides guidelines for con-
used it to estimate prevalence of alcohol tinued research on the AUDIT.
use disorders in emergency rooms (ERs)
of three regional hospitals in Thailand.
14 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Administration Guidelines
Box 3
Questionnaire Interview
Takes less time Allows clarification of ambiguous answers
Easy to administer Can be administered to patients with poor
reading skills
Suitable for computer administration
and scoring
May produce more accurate answers Allows seamless feedback to patient
and initiation of brief advice
ADMINISTRATION GUIDELINES I 17
Box 4
1. How often do you have a drink containing alco- 6. How often during the last year have you needed
hol? a first drink in the morning to get yourself going
after a heavy drinking session?
(0) Never [Skip to Qs 9-10]
(1) Monthly or less (0) Never
(2) 2 to 4 times a month (1) Less than monthly
(3) 2 to 3 times a week (2) Monthly
(4) 4 or more times a week (3) Weekly
(4) Daily or almost daily
2. How many drinks containing alcohol do you have 7. How often during the last year have you had a
on a typical day when you are drinking? feeling of guilt or remorse after drinking?
(0) 1 or 2 (0) Never
(1) 3 or 4 (1) Less than monthly
(2) 5 or 6 (2) Monthly
(3) 7, 8, or 9 (3) Weekly
(4) 10 or more (4) Daily or almost daily
3. How often do you have six or more drinks on one 8. How often during the last year have you been
occasion? unable to remember what happened the night
before because you had been drinking?
(0) Never
(1) Less than monthly (0) Never
(2) Monthly (1) Less than monthly
(3) Weekly (2) Monthly
(4) Daily or almost daily (3) Weekly
Skip to Questions 9 and 10 if Total Score (4) Daily or almost daily
for Questions 2 and 3 = 0
4. How often during the last year have you found 9. Have you or someone else been injured as a
that you were not able to stop drinking once you result of your drinking?
had started?
(0) No
(0) Never (2) Yes, but not in the last year
(1) Less than monthly (4) Yes, during the last year
(2) Monthly
(3) Weekly
(4) Daily or almost daily
5. How often during the last year have you failed to 10. Has a relative or friend or a doctor or another
do what was normally expected from you health worker been concerned about your drink-
because of drinking? ing or suggested you cut down?
(0) Never (0) No
(1) Less than monthly (2) Yes, but not in the last year
(2) Monthly (4) Yes, during the last year
(3) Weekly
(4) Daily or almost daily
Box 6
*The AUDIT cut-off score may vary slightly depending on the country’s drinking patterns, the alcohol content of
standard drinks, and the nature of the screening program. Clinical judgment should be exercised in cases where
the patient’s score is not consistent with other evidence, or if the patient has a prior history of alcohol dependence.
It may also be instructive to review the patient’s responses to individual questions dealing with dependence symp-
toms (Questions 4, 5 and 6) and alcohol-related problems (Questions 9 and 10). Provide the next highest level of
intervention to patients who score 2 or more on Questions 4, 5 and 6, or 4 on Questions 9 or 10.
patients who are not dependent on alco- CIDI39 or the SCAN40. The alcohol sections
hol36, 37, 38. A companion WHO manual, of these interviews require 5 to 10 minutes
Brief Intervention for Hazardous and to complete.
Harmful Drinking: A Manual for Use in
Primary Care, provides more information The Tenth revision of the International
on this approach. Classification of Diseases (ICD-10)4 pro-
vides detailed guidelines for the diagnosis
Referral to alcohol specialty care is common of acute alcohol intoxication, harmful use,
among those primary care practitioners alcohol dependence syndrome, withdrawal
who do not have competency in treating state, and related medical and neuropsy-
alcohol use disorders and where specialty chiatric conditions. The ICD-10 criteria for
care is available. Consideration must be the alcohol dependence syndrome are
given to the willingness of patients to described in Box 8.
accept referral and treatment. Many
patients underestimate the risks associat- Detoxification may be necessary for some
ed with drinking; others may not be pre- patients. Special attention should be paid
pared to admit and address their depen- to patients whose AUDIT responses indi-
dence. A brief intervention, adapted to cate daily consumption of large amounts
the purpose of initiating a referral using of alcohol and/or positive responses to
data from a clinical examination and questions indicative of possible depen-
blood tests, may help to address patient dence (questions 4-6). Enquiry should be
resistance. Follow-up with the patient made as to how long a patient has gone
and the specialty provider may also since having an alcohol-free day and any
assure that the referral is accepted and prior experience of withdrawal symp-
treatment is received. toms. This information, a physical exami-
nation, and laboratory tests (see Clinical
Diagnosis is a necessary step following Screening Procedures, Appendix D) may
high positive scoring on the AUDIT, since inform a judgment of whether to recom-
the instrument does not provide suffi- mend detoxification. Detoxification
cient basis for establishing a manage- should be provided for patients likely to
ment or treatment plan. While persons experience moderate to severe withdraw-
associated with the screening programme al not only to minimize symptoms, but
should have a basic familiarity with the also to prevent or manage seizures or
criteria for alcohol dependence, a quali- delirium, and to facilitate acceptance of
fied professional who is trained in the therapy to address dependence. While
diagnosis of alcohol use disorders4 should inpatient detoxification may be necessary
conduct this assessment. The best in a small number of severe cases, ambu-
method of establishing a diagnosis is latory or home detoxification can be used
through the use of a standardized, struc- successfully with the majority of less
tured, psychiatric interview, such as the severe cases.
24 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Box 8
Programme Implementation
lcohol screening and appropriate place. However, both policy and proce-
A patient care have been recognized dural decisions will be required.
widely as essential to good medical prac-
tice. Like many medical practices that It is generally helpful to involve in plan-
achieve such recognition, there is often a ning the staff who will participate in or
failure to implement effective technolo- be affected by the screening operation.
gies within organized systems of health Participation of persons with diverse per-
care. Implementation requires special spectives, experience, and responsibilities
efforts to assure compliance of individual is most likely to identify obstacles and
practitioners, overcome obstacles, and create ways to remove or surmount
adapt procedures to special circum- them. In addition, the involvement of
stances. Research into implementation staff in planning yields a sense of owner-
has begun to produce useful guidelines ship over the resulting implementation
for effective implementation43, 44. Four plan. This is likely to increase the commit-
major elements have emerged as critical ment of individuals and the group to fol-
to success: low the plan and make improvements
along the way that will assure success.
■ planning; A partial list of implementation issues on
■ training; which planning is helpful are presented
in Box 9. An implementation plan should
■ monitoring; and
receive formal approval at whatever
■ feedback. level(s) required before training begins.
Box 9
Implementation Questions
Which patients will be screened?
How often will patients be screened?
How will screening be coordinated with other activities?
Who will administer the screen?
What provider and patient materials will be used?
Who will interpret results and help the patient?
How will medical records be maintained?
What follow-up actions will be taken?
How will patients needing screening be identified?
When during the patient’s visit will screening be done?
What will be the sequence of actions?
How will instruments and materials be obtained, stored, and managed?
How will follow-up be scheduled?
Appendix A
Research Guidelines for the AUDIT
Appendix B
Suggested Format for AUDIT Self-Report Questionnaire
Box 10
Questions 0 1 2 3 4
1. How often do you have Never Monthly 2-4 times 2-3 times 4 or more
a drink containing alcohol? or less a month a week times a week
3. How often do you have six or Never Less than Monthly Weekly Daily or
more drinks on one monthly almost
occasion? daily
4. How often during the last Never Less than Monthly Weekly Daily or
year have you found that you monthly almost
were not able to stop drinking daily
once you had started?
5. How often during the last Never Less than Monthly Weekly Daily or
year have you failed to do monthly almost
what was normally expected of daily
you because of drinking?
6. How often during the last year Never Less than Monthly Weekly Daily or
have you needed a first drink monthly almost
in the morning to get yourself daily
going after a heavy drinking
session?
7. How often during the last year Never Less than Monthly Weekly Daily or
have you had a feeling of guilt monthly almost
or remorse after drinking? daily
8. How often during the last year Never Less than Monthly Weekly Daily or
have you been unable to remem- monthly almost
ber what happened the night daily
before because of your drinking?
Total
32 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Appendix C
Translation and Adaptation to Specific Languages,
Cultures and Standards
n some cultural settings and linguistic for these questions in order to fit the
Itranslated
groups, the AUDIT questions cannot be
literally. There are a number of
most common drink sizes and alcohol
strength in your country.
sociocultural factors that need to be
taken into account in addition to seman- The recommended low-risk drinking level
tic meaning. For example, the drinking set in the brief intervention manual and
customs and beverage preferences of cer- used in the WHO study on brief inter-
tain countries may require adaptation of ventions is no more than 20 grams of
questions to conform to local conditions. alcohol per day, 5 days a week (recom-
mending 2 non-drinking days).
With regard to translation into other lan-
guages, it should be noted that the AUDIT How to Calculate the Content
questions have been translated into Spanish, of Alcohol in a Drink
Slavic, Norwegian, French, German, Russian, The alcohol content of a drink depends on
Japanese, Swahili, and several other lan- the strength of the beverage and the vol-
guages. These translations are available by ume of the container. There are wide varia-
writing to the Department of Mental tions in the strengths of alcoholic bever-
Health and Substance Dependence, World ages and the drink sizes commonly used in
Health Organization, 1211 Geneva 27, different countries. A WHO survey45 indi-
Switzerland. Before attempting to trans- cated that beer contained between 2%
late AUDIT into other languages, interest- and 5% volume by volume of pure alcohol,
ed individuals should consult with WHO wines contained 10.5% to 18.9%, spirits
Headquarters about the procedures to be varied from 24.3% to 90%, and cider from
followed and the availability of other 1.1% to 17%. Therefore, it is essential to
translations. adapt drinking sizes to what is most com-
mon at the local level and to know roughly
What is a Standard Drink? how much pure alcohol the person con-
In different countries, health educators sumes per occasion and on average.
and researchers employ different defini-
tions of a standard unit or drink because Another consideration in measuring the
of differences in the typical serving sizes amount of alcohol contained in a stan-
in that country. For example, dard drink is the conversion factor of
ethanol. That allows you to convert any
1 standard drink in Canada: 13.6 g of volume of alcohol into grammes. For each
pure alcohol milliliter of ethanol, there are 0.79 grammes
1 s drink in the UK: 8 g of pure ethanol. For example,
1 s drink in the USA: 14 g
1 s drink in Australia or New Zealand: 10 g 1 can beer (330 ml) at 5% x (strength)
1 s drink in Japan: 19.75 g 0.79 (conversion factor) = 13 grammes
of ethanol
In the AUDIT, Questions 2 and 3 assume 1 glass wine (140 ml) at 12% x
that a standard drink equivalent is 10 grams 0.79 = 13.3 grammes of ethanol
of alcohol. You may need to adjust the 1 shot spirits (40 ml) at 40% x
number of drinks in the response categories 0.79 = 12.6 grammes of ethanol.
APPENDIX D I 33
Appendix D
Clinical Screening Procedures
Appendix E
Training Materials for AUDIT
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NOTES I 39
Notes
40 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST