# Assessment and Screening for Alcohol Use Disorder -- APA 2018

## Comprehensive Assessment (Statements 1-4)

### Statement 1: Assessment of Current and Past Substance Use (1C)

APA recommends (1C) that the initial psychiatric evaluation of a patient with suspected alcohol use disorder include assessment of current and past use of tobacco and alcohol as well as any misuse of other substances, including prescribed or over-the-counter medications or supplements.

Key elements to assess:
- **Quantity and frequency** of alcohol consumption
- **Pattern of use** (daily, binge, weekday vs. weekend)
- **Duration** of problematic use
- **Prior quit attempts** and their outcomes
- **Withdrawal history** (seizures, delirium tremens)
- **Tobacco, cannabis, opioid, benzodiazepine, stimulant** co-use

### Statement 2: Use of Quantitative Behavioral Measures (1C)

APA recommends (1C) that the initial psychiatric evaluation of a patient with suspected alcohol use disorder include a quantitative behavioral measure to detect the presence of alcohol misuse and determine its severity.

Recommended screening instruments:

| Instrument | Items | Positive Screen Threshold | Use Case |
|---|---|---|---|
| **AUDIT** (Alcohol Use Disorders Identification Test) | 10 | >= 8 (men), >= 4-5 (women/elderly) | Full screening in clinical settings |
| **AUDIT-C** (AUDIT-Consumption) | 3 | >= 4 (men), >= 3 (women) | Brief primary care screening |
| **CAGE** | 4 | >= 2 | Quick bedside screen |
| **DAST** (Drug Abuse Screening Test) | 10 or 28 | Varies | Polysubstance use screening |

> **OpenMedicine Calculators:** `calculate_audit_c` and `calculate_cage` -- available via MCP for automated scoring.

### Statement 3: Use of Physiological Biomarkers (2C)

APA suggests (2C) that physiological biomarkers be used to identify persistently elevated levels of alcohol consumption as part of the initial evaluation of patients with alcohol use disorder or to monitor treatment progress.

| Biomarker | Window | Notes |
|---|---|---|
| **GGT** (gamma-glutamyltransferase) | 2-3 weeks | Elevated in heavy drinking; non-specific |
| **CDT** (carbohydrate-deficient transferrin) | 2-4 weeks | More specific for heavy alcohol use |
| **%dCDT** (percent disialotransferrin) | 2-4 weeks | Most specific biomarker |
| **MCV** (mean corpuscular volume) | Months | Elevated with chronic use; slow to normalize |
| **AST/ALT ratio** | Variable | AST:ALT ratio > 2 suggestive of alcoholic liver disease |
| **PEth** (phosphatidylethanol) | 3-4 weeks | Highly specific; detects moderate-to-heavy use |
| **EtG/EtS** (ethyl glucuronide/ethyl sulfate) | 1-3 days (urine) | Detects recent use; very sensitive |
| **BAC** (blood alcohol concentration) | Hours | Acute intoxication only |

### Statement 4: Assessment of Co-Occurring Conditions (1C)

APA recommends (1C) that patients with alcohol use disorder be assessed for co-occurring conditions, including:

- **Psychiatric disorders**: major depressive disorder, bipolar disorder, anxiety disorders (generalized anxiety, social anxiety, panic disorder), PTSD, ADHD, other substance use disorders
- **Medical comorbidities**: liver disease (hepatitis, cirrhosis, fatty liver), pancreatitis, cardiomyopathy, peripheral neuropathy, Wernicke-Korsakoff syndrome, malnutrition
- **Cognitive impairment**: alcohol-related neurocognitive disorder
- **Suicidality**: active and passive suicidal ideation, prior attempts

```
Patient with suspected AUD
  -> Administer AUDIT-C or full AUDIT
      -> AUDIT-C >= 4 (men) or >= 3 (women)? -> Positive screen
          -> Proceed to DSM-5 diagnostic criteria assessment
          -> Assess severity (mild/moderate/severe)
      -> AUDIT-C < threshold? -> Low-risk or non-drinker
          -> Reassess periodically
  -> Assess co-occurring psychiatric conditions
  -> Assess medical comorbidities
  -> Obtain physiological biomarkers (GGT, CDT, hepatic panel)
  -> Assess withdrawal risk and history
```

## DSM-5 Diagnostic Criteria for Alcohol Use Disorder

A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by **at least 2 of the following 11 criteria** occurring within a **12-month period**:

| # | Criterion |
|---|---|
| 1 | Alcohol often taken in larger amounts or over a longer period than intended |
| 2 | Persistent desire or unsuccessful efforts to cut down or control alcohol use |
| 3 | Great deal of time spent obtaining, using, or recovering from alcohol |
| 4 | Craving, or a strong desire or urge to use alcohol |
| 5 | Recurrent alcohol use resulting in failure to fulfill major role obligations |
| 6 | Continued alcohol use despite persistent or recurrent social or interpersonal problems |
| 7 | Important social, occupational, or recreational activities given up or reduced |
| 8 | Recurrent alcohol use in situations in which it is physically hazardous |
| 9 | Continued use despite knowledge of persistent or recurrent physical or psychological problem |
| 10 | Tolerance (need for increased amounts or diminished effect) |
| 11 | Withdrawal (characteristic syndrome or substance taken to relieve/avoid withdrawal) |

### Severity Classification

| Severity | Number of Criteria Met | Clinical Implications |
|---|---|---|
| **Mild** | 2-3 | Brief intervention, motivational interviewing; pharmacotherapy may be considered |
| **Moderate** | 4-5 | Pharmacotherapy recommended (naltrexone or acamprosate); psychosocial treatment |
| **Severe** | 6 or more | Pharmacotherapy strongly recommended; intensive outpatient or residential treatment may be needed |

## Treatment Goals (Statement 5)

APA suggests (2C) that the initial goals of treatment of alcohol use disorder (e.g., abstinence from alcohol use, reduction or moderation of alcohol use, other elements of harm reduction) be agreed on between the patient and clinician and that this agreement be documented in the medical record.

- **Abstinence** is the optimal goal for patients with severe AUD, significant medical comorbidities, or prior severe withdrawal.
- **Reduction in drinking** is an acceptable initial goal, particularly for patients who are ambivalent about abstinence.
- Goals should be **patient-centered** and revisited throughout treatment.

## Review of Risks (Statements 6-7)

### Statement 6: Legal Obligations (2C)

APA suggests (2C) that clinicians discuss the patient's legal obligations (e.g., court-mandated abstinence, monitoring requirements) and document this discussion.

### Statement 7: Risks to Self and Others (2C)

APA suggests (2C) that clinicians discuss risks to self (e.g., physical health, occupational functioning, legal involvement) and others (e.g., impaired driving, domestic violence, fetal alcohol spectrum disorder in pregnancy) from continued alcohol use and document this discussion.

## Limitations

- The AUDIT-C, while validated, does not assess criteria required for an AUD diagnosis as defined by DSM-5 and does not provide information about the number of AUD criteria present, which is required for determining AUD severity.
- Biomarkers such as GGT and CDT have limited sensitivity in detecting lower-risk drinking and may be elevated by conditions unrelated to alcohol use.
- DSM-5 severity categories (mild, moderate, severe) are based on symptom counts and may not fully capture functional impairment or treatment urgency in all cases.
