Available Screening Tools

There are a variety of validated screening tools, each of which differs on several dimensions, including:

What is being screened?

  • Are they specific to alcohol use only?
  • Do they cover alcohol and other drugs?

What is the method of administration?

  • Self administered?
  • Administered as part of a clinical interview?

Are they designed for special populations?

  • Pregnant patients?
  • College students?
  • Adolescents?
  • ED Patients?

Screening instruments also vary somewhat in length, from the fairly comprehensive ASSIST, which can take up to 10 minutes to complete, to the very brief, comprised on only a couple initial questions.

Screening Tests at a Glance

While the following table is not comprehensive nor does it cover all potential screening tools, it provides a good summary of test names, type of screening, method(s) of administration, and whether it is designed for a specific special population.

Test What is Being Screened Method of Administration Special Population
AUDIT Alcohol Self or interview No
CAGE Alcohol Interview No
MAST Alcohol Self or interview No
T-ACE Alcohol Interview Women/pregnant women
TWEAK Alcohol Interview Pregnant women
AUDIT-C Alcohol Self or interview No
DAST Drugs (not alcohol) Self No
ASSIST Alcohol, tobacco, illicit drugs Self or Self and Interview No

Which screening tool you use will be in part dependent on personal preference, experiences, and the nature of the environment in which you practice. Most of the above screening tools have been extensively validated and have evidence supporting their efficacy. The important thing: choose a screening method and use it with all of your patients. It will become second nature both to you and, importantly, to your patients

Screening Tools for Adolescent Substance Use

As you can see, many tools exist for screening patients but not every tool is effective for screening adolescents. The CRAFFT questionnaire is a simple, brief tool that can be administered via paper or computer or verbally. The tool was developed to screen adolescents 14 years and older for high-risk alcohol and other drug use disorders simultaneously. CRAFFT is a mnemonic acronym of key words in 6 screening questions preceded by opening questions and is administered in 2 stages.

The first stage begins with asking 3 opening questions:

Please answer these questions honestly. During the past 12 months, did you:

  1. Drink any alcohol (more than a few sips)?
  2. Smoke any marijuana or hashish?
  3. Use anything else to get high? (note: “anything else” refers to illegal drugs, over-the-counter or prescription drugs, and things that you sniff or “huff”)

The second stage depends on the answers to the stage one questions:

  • If the answers to all the opening questions are “no,” ask only the CAR question (see below) from CRAFFT
  • If any of the answers are “yes,” proceed with all 6 questions

CRAFFT Questionnaire

  • Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
  • Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
  • Do you ever use alcohol or drugs while you are by yourself, or ALONE?
  • Do you ever FORGET things you did while using alcohol or drugs?
  • Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
  • Have you ever gotten into TROUBLE while you were using alcohol or drugs?

A score of 2 or more “yes” answers on the actual CRAFFT questions is considered a positive screen and indicates a high risk for substance abuse.

Which screening tool you use will be in part dependent on personal preference, experiences, and the nature of the environment in which you practice. Most of the above screening tools have been extensively validated and evidence supporting their efficacy. The important thing: choose a screening method and use it with all of your patients. It will become second nature both to you and, importantly, to your patients.

Screening Tools for Substance Use in Pregnant Patients

As you can see, many tools exist for screening patients but not every tool is effective for screening pregnant patients. The T-ACE and TWEAK screening tools have been validated for the use of screening for alcohol use in pregnant patients.

The T-ACE was the first validated sensitive screen for risky drinking in pregnant women. Interestingly, an obstetrician developed the T-ACE after observing that asking patients about their tolerance to the intoxicating effects of alcohol did not trigger denial.

T-ACE

Tolerance: How many drinks does it take to make you feel high?

Have people Annoyed you by criticizing your drinking?

Have you ever felt you ought to Cut down on your drinking?

Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

One point is given for each affirmative answer to the A, C, or E questions. Two points are given when a pregnant woman reports that more than two drinks are necessary for her to feel “high” or experience the intoxicating effects of alcohol. A score of 2 or more on the T-ACE is considered positive for at-risk alcohol use.

The TWEAK is a validated five-item screening tool for risky alcohol use in pregnant women. Like the T-ACE, it asks a question about tolerance that is weighted higher than the other questions when scoring.

TWEAK

Tolerance: How many drinks can you hold?

Have close friends or relatives Worried or complained about your drinking in the past year?

Eye Opener: Do you sometimes take a drink in the morning when you get up?

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 downon your drinking?

The TWEAK is scored on a 7-point scale. On the tolerance question, 2 points are given if a woman reports that she can consume more than five drinks without falling asleep or passing out. A positive response to the worry question yields 2 points, and positive responses to the last three questions yield 1 point each. A score of 2 or more on the TWEAK is considered positive for at-risk alcohol use.

Few validated tools exist for screening pregnant women for illicit drug use. One tool with good sensitivity and specificity for illicit drug use is the 4P Plus.

4P Plus

Parents:     Did either of your have any problems with drugs or alcohol?

Partner:     Does your partner have any problem with drugs or alcohol?

Is your partner’s temper ever a problem for you?

Past:                   Have you ever drunk beer/wine/liquor?

Pregnancy:         In the month before you knew you were pregnant, how many cigarettes did you smoke?

In the month before you knew you were pregnant, how much beer/wine/liquor did you drink?

Plus:          In the month before you knew you were pregnant, how much marijuana did you use?

Depending on the answers to these questions, a woman is categorized by her predicted risk status. In one of the original studies of this tool by Chasnoff et al, those women who had never used alcohol were considered low risk because they had only a 1.4% risk of using tobacco, alcohol or drugs during their pregnancy. Those women who had used alcohol in the past but not in the month before pregnancy and did not smoke >3 cigarettes in the month before pregnancy were considered average risk (9% of these were found to be using alcohol or drugs during their pregnancy). Lastly, those women who used any alcohol or smoked >3 cigarettes in the month before pregnancy were considered high-risk (34% of these were found to be using alcohol or drugs during their pregnancy).

Any positive answers to the Pregnancy or Plus questions requires further assessment regarding how often and what kind of substances were and are currently used. If no current use, no referral is needed. Educational interventions and substance abuse treatment is reserved for regular use of alcohol or illicit drugs.

Which screening tool you use will be in part dependent on personal preference, experiences, and the nature of the environment in which you practice. Most of the above screening tools have been extensively validated and evidence supporting their efficacy. The important thing: choose a screening method and use it with all of your patients. It will become second nature both to you and, importantly, to your patients.

Chan AK et al. The TWEAK test in screening for alcoholism/ heavy drinking in three populations. Alcoholism: Clinical and Experimental Research 6: 1188 1192, 1993.

Chasnoff IJ, McGourty RF, Bailey GW, Hutchins E, Lightfoot SO, Pawson LL, et al. The 4P’s Plus screen for substance use in pregnancy: clinical application and outcomes. J Perinatol 2005;25:368–74.

Sokol RJ, Martier SS and Ager SS. The T-ACE questions: Practical prenatal detection of risk-drinking. American Journal of Obstetrics and Gynecology 160: 863 871, 1989.

 

The screening process follows the same steps regardless of the instrument; in other words, the instrument is the tool that is used in the process, not the process itself.

Stepwise Approach to Alcohol Screening and Assessment

You do not have to jump right into using the instruments, some of which are a bit long (even 5-6 questions can seem ‘long’ in a patient visit). Instead, we often do the “two-step”: ask generally about use of a substance, then, if the patient responds positively about use, move toward a validated screening instrument. For example, for alcohol.

  1. Pre-screen patients with simple quantity and frequency questions.
    1. Do you sometimes drink beer, wine, or other alcoholic beverages?
    2. If yes, how many times in the past year have you had 4 (women) or 5 (men) drinks or more in a day?
  2. If the patient reports a positive score, use the appropriate screening instrument (introduced in the previous section) to determine risk of harm for this patient.