Screening for Alcohol Misuse

Defining Drinking

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines three different drinking levels: moderate alcohol consumption, binge drinking and heavy drinking. Per the Dietary Guidelines for Americans 2015-2020 (Appendix 9) moderate drinking is defined as consuming up to one drink per day for females and up to two drinks per day for males. Binge drinking is defined by the NIAAA as “a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL” (grams per deciliter), which typically occurs after four drinks in two hours for females and five drinks in two hours for males. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines binge drinking as “drinking five or more alcoholic drinks on the same occasion on at least one day in the past 30 days.” SAMHSA defines heavy drinking as “drinking five or more drinks on the same occasion on each of five or more days in the past 30 days. [ Reference 1 ]

The risk of alcohol-related consequences, such as physical, psychological or social harm, increases with greater levels of consumption. Short-term risks of drinking include injury and trauma, [ Reference 2 ] while long-term risks include cirrhosis, cancer and other chronic illnesses. [ Reference 3 ]

NIAAA-Recommended Drinking Limits [ Reference 4 ]


No more than 14 standard-size drinks in a week and no more than 4 standard-size drinks on any occasion


No more than 7 standard-size drinks in a week and no more than 3 standard-size drinks on any occasion

Standard-size drinks are:

  • 12 oz. beer (~5% alcohol)
  • 8-9 oz. malt liquor (~7% alcohol)
  • 5 oz. wine (~12% alcohol)
  • 1.5 oz. hard liquor (~40% alcohol)

The United States Preventive Services Task Force (USPSTF) ranked unhealthy alcohol use screening and counseling the third of the top five prevention priorities for adults in the United States. According to the Department of Veterans Affairs /Department of Defense (DoD) Clinical Practice Guideline for the Management of Substance Use Disorders, screening should be conducted annually for patients in general medical and mental health care settings using the three-item Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) or Single Item Alcohol Screening Questionnaire (SASQ).

  1. The AUDIT-C was developed by the World Health Organization (WHO). It is a brief alcohol screen that can help identify patients who engage in hazardous drinking or have active alcohol use disorders.[ Reference 4 ]
  2. The SASQ is a single-item screen that is often easier to integrate into clinical interviews as primary care providers may be unlikely to recall response options and scoring for the AUDIT-C.

A Positive Screen

A screening for unhealthy alcohol use is considered positive if an individual obtains:

  • An AUDIT-C score of greater than or equal to four points for men and greater than or equal to three points for females.
  • On the SASQ if individuals report drinking four or more drinks on an occasion (female) or five or more drinks (males) on an occasion in the past year.

Patients without documented alcohol use disorder who screen positive for unhealthy alcohol use should be provided a single initial brief intervention regarding alcohol-related risks and advice to abstain or drink within nationally established age and gender-specific limits for daily and weekly consumption. [ Reference 5 ]

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

SAMHSA‘s Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for individuals with substance use disorders, as well as those who are at risk of developing these disorders. Primary care centers, hospital emergency rooms, trauma centers and other community settings provide opportunities for early intervention with people at risk for substance misuse before more severe consequences occur.

The SBIRT process consists if the following elements:

Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment.

Brief Intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.

Referral to Treatment provides those identified as needing more extensive treatment with access to specialty care.

Within the Military Health System, DoD piloted the SBIRT approach in primary care to address alcohol misuse. It found that SBIRT is a feasible and effective process and is improved through the use of ongoing training for providers and clinical tools to help providers educate beneficiaries. Several clinical resources were developed as part of the pilot to help patients understand facts about alcohol misuse and standard drink size, as well as employ self-management strategies to track their alcohol consumption and plan for positive changes in drinking habits.

Consideration to Co-occurring Disorders with Substance Misuse

Some individuals with alcohol and substance misuse have co-occurring psychosocial problems that affect their likelihood of establishing and maintaining good clinical outcomes and improved functional status. [ Reference 6 ]

Several mental health conditions, such as bipolar disorders, schizophrenia and antisocial personality disorder, are associated with increased rate of alcohol use disorder.

Anxiety and depressive disorders may also correlate with alcohol use disorder.[ Reference 7 ]

Individuals with other substance use disorders are similarly at increased risk for the development of mild to moderate depressive disorders due to effects of the substance or as an exacerbation of a preexisting depressive disorder.

Insomnia, antisocial personality disorder and posttraumatic stress disorder are conditions more common to those with substance use disorders than those without them.[ Reference 8 ]

Individuals with alcohol and substance use disorders may have more than one substance use disorder.

Opioid use disorder is often associated with other substance use disorders, especially those involving tobacco, alcohol, cannabis, stimulants and benzodiazepines.

Substances may be taken to reduce symptoms of opioid withdrawal or craving for opioids, or to enhance the effects of administered opioids.[ Reference 9 ]

Those individuals with alcohol and substance use disorders may also have co-occurring physical conditions.

Drinking alcohol at levels above weekly or daily limits can damage the heart, interfere with brain communication pathways, lead to liver inflammation and other liver problems, weaken the immune system, and increase the risk of developing mouth, throat, esophagus, liver and breast cancer, according to the NIAAA.

Substance misuse can directly or indirectly lead to significant co-occurring health conditions to include cardiovascular disease, stroke, cancer, HIV/AIDS, hepatitis and lung disease. [ Reference 9 ]