Putting Prevention into Practice

An Evidence-Based Approach

Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse


Am Fam Physician. 2004 Nov 1;70(9):1743-1744.

Case Study

MN, a 25-year-old woman, visits your office for evaluation of insomnia. As part of her social history, she tells you that she is a “social drinker.” Further questioning reveals that she drinks about as much as she did during college. You want to better assess her alcohol use.

Case Study Questions

  1. Which of the following is/are validated screening tools for alcohol misuse in adults in primary care?

    • A. The Alcohol Use Disorders Identification Test (AUDIT).

    • B. The CAGE questionnaire.

    • C. The 5-A’s behavioral counseling framework.

    • D. The CRAFFT questionnaire.

  2. Which one of the following statements about behavioral counseling for alcohol misuse is correct?

    • A. Behavioral counseling interventions in adolescents decrease alcohol misuse.

    • B. Behavioral counseling interventions in adults decrease alcohol misuse.

    • C. Behavioral counseling interventions for alcohol misuse clearly reduce alcohol-related morbidity in adults.

    • D. Effective initial counseling interventions should last at least one hour.

    • E. Effective counseling interventions must be delivered by physicians.

  3. Which one of the following statements about screening and counseling for alcohol misuse is correct?

    • A. The 5-A’s behavioral counseling framework is useful for delivering a counseling intervention.

    • B. Patients should follow up monthly to monitor progress in reducing alcohol misuse.

    • C. Patients who test negative for alcohol misuse should be rescreened every six months.

    • D. Serum gamma-glutamyltransferase (GGT) level is a useful test for detecting alcohol misuse.

    • E. The serum carbohydrate-deficient transferrin (CDT) level is a useful test for detecting alcohol misuse.


1. The correct answers are A and B. Alcohol misuse includes both harmful drinking and risky or hazardous drinking. Harmful drinking is defined as drinking at a level that causes physical, social, or psychologic harm, but not to the level of alcohol dependence. Risky or hazardous drinking is more than seven drinks per week or more than three drinks per occasion for women, and more than 14 drinks per week or more than four drinks per occasion for men. Approximately 8 to 18 percent of general primary care patients would screen positive for alcohol misuse using any validated instrument.

AUDIT and the CAGE questionnaire are validated for screening adults in the primary care setting. AUDIT addresses drinking frequency, quantity, and consequences. CAGE (feeling the need to Cut down, Annoyed by criticism, Guilty about drinking, and need for an Eye-opener in the morning) is the most popular screening test in primary care for detecting alcohol abuse or dependence. The 5-A’s (Assess, Advise, Agree, Assist, Arrange) is a framework for behavioral counseling and is not an alcohol screening tool. The CRAFFT questionnaire, a new tool developed for screening adolescents, needs to be validated in the primary care setting. For more details on screening tools, see:http://www.niaaa.nih.gov/publications/arh21-4/348.pdf.

2. The correct answer is B. The U.S. Preventive Services Task Force (USPSTF) found that behavioral counseling interventions with follow-up are effective in producing small to moderate reductions in alcohol consumption in adults who misuse alcohol. However, no study showed a statistically significant reduction in long-term alcohol-related morbidity. Studies on behavioral counseling in adolescents have reported conflicting results. Initial counseling sessions of about 15 minutes are effective. Effective counseling interventions can be delivered wholly or in part in the primary care setting and by one or more members of a health care team, including physician and non-physician practitioners.

3. The correct answer is A. The 5-A’s are a useful framework for behavioral counseling and include the following elements:

Assess alcohol consumption with a brief screening tool followed by clinical assessment as needed.

Advise patients to reduce alcohol consumption to moderate levels.

Agree on individual goals for reducing alcohol use or abstinence (if indicated).

Assist patients with acquiring the motivation, self-help skills, and support needed for behavior change.

Arrange follow-up support and repeated counseling, including referring dependent drinkers for specialty treatment.

The optimal intervals for delivering interventions or for rescreening for alcohol misuse in patients who previously have tested negative are not known. Biologic markers, such as CDT and GGT levels, are poor tests to detect alcohol misuse.

CRAIG M. HALES M.D., M.P.H., Resident, preventive medicine, Johns Hopkins Bloomberg School of Public Health

GURVANEET RANDHAWA, M.D., M.P.H., Program Director, U.S. Preventive Services Task Force Center for Primary Care, Prevention & Clinical Partnerships, Agency for Healthcare Research and Quality


U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med. 2004;140:554–6.

Whitlock EP, Green CA, Polen MR. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use. Systematic evidence review No. 30. Prepared by the Oregon Evidence-based Practice Center under Contract No. 290-97-0018. Rockville, Md.: Agency for Healthcare Research and Quality, 2004. Accessed online September 24, 2004, at:http://www.ahrq.gov/clinic/prev/alcoinv.htm.

Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:557–68.

The case study and answers to the following questions on screening and behavioral counseling interventions in primary care to reduce alcohol misuse are based on the recommendations of the U.S. Preventive Services Task Force (USPSTF), part of the Put Prevention into Practice program of the Agency for Healthcare Research and Quality (AHRQ). This recommendation was released in 2003. More detailed information on this subject is available in the USPSTF recommendation statement, the summary of the evidence, and the systematic evidence review on the USPSTF Web site (http://www.ahrq.gov/clinic/uspstfix.htm). The summary of the evidence and recommendation statement are available in print by subscription through the AHRQ Publications Clearinghouse (telephone: 800-358-9295, e-mail:ahrqpubs@ahrq.gov).

This case study is part of AFP’s CME. See “Clinical Quiz” on page 1633.



Copyright © 2004 by the American Academy of Family Physicians.
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