The following is the Veterans Health Administration/Department of Defense Substance Use Disorder Guidelines for primary care. The VA requires screening for both heavy drinking and alcohol use disorders because both are associated with increased morbidity and mortality. Medical problems due to alcohol dependence include alcohol withdrawal syndrome, psychosis, hepatitis, cirrhosis, pancreatitis, thiamine deficiency, neuropathy, dementia, and cardiomyopathy. Alcohol dependence represents only one end of the spectrum of "hazardous or problem drinking". Many drinkers have medical or social problems attributable to alcohol without typical signs of dependence, and other asymptomatic drinkers are at risk for future problems due to chronic, heavy alcohol consumption or frequent binges (i.e., "hazardous drinking"). Nondependent heavy drinkers account for the majority of alcohol-related morbidity and mortality in the general population. There is a dose-response relationship between average daily alcohol consumption and elevations in blood pressure and risk of cirrhosis, hemorrhagic stroke, trauma and cancers of the oropharynx, larynx, esophagus, and liver (Rehm et al., 2003). Based on the accumulated epidemiological evidence, individuals who drink above the following levels are at increased risk for adverse consequences of drinking: 14 drinks/week typically for men, 7 drinks/week for women; 5 or more drinks on an occasion for men; 4 or more dinks on an occasion for women (NIAAA 2003). Alcohol screening is recommended for all adult and adolescent patients. Screening is not aimed just at alcohol dependent individuals, but also at the far larger population of patients at risk for problems due to drinking who can benefit from brief primary care counseling (Moyer et al., 2002). Acceptable screening instruments: The 3-item AUDIT-C for annual alcohol screening is the only acceptable instrument. (See AUDIT-C Frequently Asked Questions; FAQ). When used alone, the CAGE questionnaire, a validated screening test for alcohol abuse and dependence, is no longer sufficient for primary care alcohol screening, since it does not adequately identify patients at risk due to heavy drinking. (Bradley et al., 1998). If desired, sites can elect to use the AUDIT-C followed by the CAGE or the full AUDIT (that includes the AUDIT-C as the first 3 items), but the AUDIT-C alone is an effective screening test for both heavy drinking and alcohol use disorders. Routine measurement of biochemical markers is not recommended in asymptomatic persons. Pregnant women or women trying to conceive should not drink at all. Recommended AUDIT-C Screening thresholds: Men with an AUDIT-C score of 4 or more, or women with an AUDIT-C score of 3 or more, are "at-risk" for problems due to drinking and warrant further assessment. (see AUDIT-C FAQ's) References and Resources: • AUDIT-C Frequently Asked Questions will be posted on the OQP website • OQP website for VHA/DoD guideline module on screening for hazardous use http://www.oqp.med.va.gov/cpg/SUD/SUD_CPG/ModuleA/Frameset.htm • OQP website for VHA/DoD full guideline http://www.oqp.med.va.gov/cpg/SUD/SUD_Base.htm • New manual for the AUDIT from the World Health Organization, http://www.who.int/substance_abuse/PDFfiles/auditbro.pdf • Bradley KA, Bush K, McDonell? MB, Malone T, Fihn SD: Screening for problem drinking: comparison of CAGE and AUDIT. J Gen Intern Med, 1998;13:379-388. • 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. Arch Intern Med, 1998;158:1789-1795 • Moyer A, Finney JW, Swearingen CE, Vergun P: Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction, 2002;97:279-292. • NIAAA: Helping Patients with Alcohol Problems: A Health Practitioners Guide. NIH Publication No. 03-3769, January 2003. http://www.niaaa.nih.gov/publications/Practitioner/HelpingPatients.htm • Rehm J, Room R, Graham K, Monteiro M, Gmel G, Sempos CT. The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. Addiction, 2003;98(9):1209-28. • U. S. Department of Health and Human Services (1997). A Guide to Substance Abuse Services for Primary Care Clinicians (Tip #24), (DHHS Publication No. (SMA) 97-3139). Rockville, MD: Department of Health and Human Services. • U. S. Preventive Services Task Forces (PSTF) (1996). Guide to Clinical Preventive Services (2nd ed.). Baltimore, MD: Williams & Wilkins. Assessment of unhealthy and dependent alcohol use can include laboratory tests (for corroboration only and not for routine screening)-- e.g., blood or breath alcohol levels, breath carbon monoxide for smoking, urine toxicology, elevated carbohydrate deficient transferrin, increased mean corpuscular volume (MCV), or gamma glutamic transferase (GGT). Laboratory tests are not recommended for screening of asymptomatic persons (U.S. PSTF, 1996). The clinician should identify patients who are currently using substances at hazardous levels whether or not they meet diagnostic criteria for substance abuse or dependence (Reid et al., 1999). I. Hazardous Alcohol Use: Screen current users for hazardous alcohol use at the initial clinic visit or at least annually. 1. Screening for hazardous alcohol use should consider both the volume (e.g., total drinks per week) and pattern of use (e.g., frequency of heavy drinking episodes). o Average weekly or daily quantity is most strongly related to chronic health risks. o Frequency of heavy drinking is most strongly related to acute health risks and psychosocial risks. 2. Patients are at increased risk of medical morbidity and dependence if they report drinking more than the gender specific hazardous use threshold (Bradley et al., 1998) (see Table 1. Hazardous Alcohol Use Screening). Other Hazardous Substance Use: 1. Screen all patients for nicotine usage. 2. Determination of hazardous use for other drugs (where criteria for abuse or dependence are not met) is not well studied. There are no unequivocal quantity or frequency risk thresholds for hazardous use of psychoactive drugs. Any use may impair judgment or performance and involves some degree of risk. However, regular use of any intoxicant (e.g., daily or several days per week) suggests at the least a high risk for abuse or dependence. Some drugs, such as cocaine and heroin, are potentially toxic even with occasional use. Individuals using intoxicants such as cannabis, amphetamines, heroin, or cocaine should be cautioned about the health risks associated with such use and urged to discontinue use. 3. Long-term use of prescribed opioids, anxiolytics, or hypnotics does not in itself constitute hazardous use, abuse, or dependence. However, use of these medications must be carefully considered in each case. Many of the same considerations are relevant to long-term prescription of anxiolytics and hypnotics. Clear indications of problematic use include frequent early requests for refills, escalating demands for dose increases beyond that justified by the medical condition, attempts to obtain prescriptions from multiple providers, episodes of intoxication, or use of medications with intoxicants such as alcohol or illicit drugs. When in doubt about whether use is hazardous or abusive, consult a specialist in the management of the underlying disorder (e.g., pain, insomnia, or anxiety) or addiction medicine. II. Screening for substance abuse or dependence (Fiellin et al., 2000): Consider a screen positive for alcohol abuse or dependence, if a patient: 1. Scores eight or more on the Alcohol Use Disorders Identification Test (AUDIT) (see Appendix A-1) or 2. Endorses two or more of the four items reflected in the acronym CAGE (see Appendix A): o Have you ever felt you should cut down on your drinking? o Have people annoyed you by criticizing your drinking? o Have you ever felt bad or guilty about your drinking? o Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)? Other Substance Abuse or Dependence: 1. Screening for other drug use may be appropriate in some clinical settings (e.g., adolescent or AIDS clinics), but has not been recommended as routine by the U. S. PSTF. 2. The Drug Abuse/Dependence Screener is a 3-item screen with excellent preliminary validity in community populations. It may be useful in primary care settings when the provider identifies an indication for screening. 3. The Two-Item Conjoint Screen (TICS) has been used in primary care to identify patients with current alcohol or other drug problems. 4. The Drug Abuse Screening Test (DAST) is a 28-item (or abbreviated 10-item version) instrument to identify adverse consequences of substance abuse, but it has not been well studied in primary care settings. DSM-IV Criteria for Substance Abuse (APA, 1994): 1. A maladaptive pattern of substance abuse leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12-month period: o Recurrent substance use resulting in 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; or neglect of children or household). o Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine). o Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct). o Continued substance use despite 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 or physical fights). 2. These symptoms must never have met the criteria for substance dependence for this class of substance. Assessment of Substance Dependence: 1. a. Conduct clinical assessment to see if the patient meets the DSM-IV diagnostic criteria for Substance Dependence (e.g., see 304.30, 304.20, 304.60, 304.00, 304.90, 304.10, 304.80, or 305.1 in DSM-IV, pages 175-272). b. Diagnostic criteria required for Substance Dependence involves more than evidence of physiological dependence. c. Consider whether the person is dependent on multiple substances. DSM-IV Criteria for Substance Dependence (APA, 1994): A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three or more of the following seven criteria, occurring at any time in the same 12-month period: 1. Tolerance, as defined by either of the following: o A need for markedly increased amounts of the substance to achieve intoxication or desired effect. o Markedly diminished effect with continued use of the same amount of the substance. 2. Withdrawal, as defined by either of the following: o The characteristic withdrawal syndrome for the substance (refer to DSM-IV for further details). o The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. 3. The substance is often taken in larger amounts or over a longer period than was intended. 4. There is a persistent desire or there are unsuccessful efforts to cut down or control substance use. 5. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances to see one), use the substance (e.g., chain smoking), or recover from its effects. 6. Important social, occupational, or recreational activities are given up or reduced because of substance use. 7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression or continued drinking despite recognition that an ulcer was made worse by alcohol consumption). Dependence exists on a continuum of severity: remission requires a period of at least 30 days without meeting full diagnostic criteria and is specified as Early (first 12 months) or Sustained (beyond 12 months) and Partial (some continued criteria met) versus Full (no criteria met) (APA, 1994). III. Screening for risk of relapse A relapse is defined as any discrete violation of a self imposed rule or set of rules governing the ability to either stay completely free of drug use or maintain a preset goal of reduced drug usage. Variables that may place an individual at increased risk for relapse include the following: 1. Negative/unpleasant emotional states (e.g., anger, frustration, depression, boredom, or anxiety) 2. Interpersonal conflict 3. Social pressure to engage in drug usage (may be direct or indirect) 4. Negative physical states (e.g., chronic or acute pain or substance withdrawal) 5. Testing personal control over the use of the substance 6. Responsivity to substance cues (e.g., cravings or urges) A simple and brief patient inquiry will often suffice, such as "Have you had any 'close calls' with drinking or other drug use?"

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