04 - 4. Alcohol rating scales

4. Alcohol rating scales:

© SPMM Course 4. Alcohol rating scales: CAGE Questions: 1. Have you ever felt like cutting down on your drinking? 2. Have people annoyed or criticized you for drinking? 3. Have you ever felt bad or guilty about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? A positive answer should raise suspicion of an alcohol problem, and a score of 2 is highly suggestive. The instrument takes less than a minute to administer. AUDIT: Alcohol Use Disorders Identification Test; Saunders et al., 1993: This is a 10-item questionnaire, covering quantity, frequency, inability to control drinking, withdrawal relief, loss of memory, injury and concern by others. A score of 8 or more indicates that the person is drinking to a degree that is harmful or hazardous, whereas a score of 13 or more in women and 15 or more in men is indicative of dependent drinking. It is widely used and recommended by WHO for primary care use. MAST: Michigan Alcohol Screening Test (Selzer, 1971): This is a simple, self-report, 25-item test, which has yes/no answers. A score of 3–5 is an early indicator of a problem drinker, whereas someone who scores 6 or more is highly likely to be a problem drinker. There are variants on this test, e.g. the Brief MAST, which can discriminate problem drinkers from nonproblem drinkers on the basis of 10 items only. There are also a G-MAST and a Brief G-MAST for older people with slightly different phraseology. CIWA: Clinical Institute Withdrawal Assessment for Alcohol: (Sullivan et al., 1989) Health professionals use this scale to rate the severity of alcohol withdrawal. It consists of 10 items, 9 of which can be scored in a range of 0–7 and one on a range of 0–4 (total of 67). It can be used regularly throughout the day and night to assess the extent of withdrawal and the impact of treatment. It covers nausea; tremor; paroxysmal sweating; anxiety; agitation; auditory, visual and tactile disturbances; headache and orientation.