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    >>>18.16 Psychological Measures of Alcohol Abuse

    >>>18.16.01 The Obsessive Compulsive Dri!ig "cale

    Overview:

    The Obsessive Compulsive Drinking Scale is a self-rating instrument that measures some of

    the cognitive aspects of alcohol craving and which may be useful in assessing the severity of

    alcoholism and treatment outcome.

    dministration:

    The sub!ect fills out the "uestionnaire indicating the answer to each "uestion which bests

    applies to him#herself. The test can be administered before during and after treatment

    intervention.

    # $ues%io

    &alue

    1 $ow much of your time when you%re not drinking is occupied byideas thoughts impulses or images related to drinking&

    ' none (

    ' less than ) hour per day )

    ' )-* hours a day +

    ' ,- hours a day *

    ' greater than hours a day ,

    ' $ow fre"uently do these thoughts occur&

    ' never (

    ' no more than times a day )

    ' more than times a day but most hours of the day are free ofsuch thoughts +

    ' more than times a day and during most hours of the day *

    ' thoughts are too numerous to count and an hour rarely passes

    without several such thoughts occurring

    ,

    ( $ow much do these ideas thoughts impulses or images related to

    drinking interfere with your social or work /or role0 functioning&

    /1f you are not currently working how much of your performance

    would be affected if you were working&0

    ' thoughts of drinking never interfere - 1 can function normally (

    ' thoughts of drinking slightly interfere with my social or

    occupational activities but my overall performance is not impaired

    )

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    ' thoughts of drinking definitely interfere with my social or

    occupational performance but 1 can still manage

    +

    ' thoughts of drinking cause substantial impairment of my social or

    occupational performance

    *

    ' thoughts of drinking interfere completely with my social or work

    performance

    ,

    ) $ow much distress or disturbances do these ideas thoughts

    impulses or images related to drinking cause you when you%re not

    drinking&

    ' none (

    ' mild infre"uent and not too disturbing )

    ' moderate fre"uent and disturbing but still manageable +

    ' severe very fre"uent and very disturbing *

    ' e2treme nearly constant and disabling distress ,

    * $ow much of an effort do you make to resist these thoughts or try

    to disregard or turn your attention away from these thoughts asthey enter your mind when you%re not drinking&

    /3ate your efforts made to resist these thoughts not your success or

    failure in actually controlling them.0

    ' 4y thoughts are so minimal 1 don%t need to actively resist. 1f 1

    have thoughts 1 make an effort to always resist.

    (

    ' 1 try to resist most of the time. )

    ' 1 make some effort to resist. +

    ' 1 give in to all such thoughts without attempting to control them

    but 1 do so with some reluctance.

    *

    ' 1 completely and willingly give in to all such thoughts. ,

    6 $ow successful are you in stopping or diverting these thoughts

    when you%re not drinking&

    ' 1 am completely successful in stopping or diverting such

    thoughts.

    (

    ' 1 am usually able to stop or divert such thoughts with some effort

    and concentration.

    )

    ' 1 am sometimes able to stop and divert such thoughts. +

    ' 1 am rarely successful in stopping such thoughts and can only

    divert such thoughts with difficulty.

    *

    ' 1 am rarely able to divert such thoughts even momentarily. ,

    + $ow many drinks do you drink each day&

    ' none (

    ' less than one drink per day )

    ' )-+ drinks per day +

    ' *-5 drinks per day *

    ' or more drinks per day ,

    8 $ow many days each week do you drink&

    ' none (

    ' no more than ) day per week )

    ' +-* days per week +

    ' ,-6 days per week * ' -5 days per week ,

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    , $ow much does your drinking interfere with your work

    functioning& 1s there anything that you don%t or can%t do because of

    your drinking& /1f you are not currently working how much of your

    performance would be affected if you were working&0

    ' Drinking never interferes - 1 can function normally. (

    ' Drinking slightly interferes with my occupational activities butmy overall performance is not impaired.

    )

    ' Drinking definitely interferes with my occupational performance

    but 1 can still manage.

    +

    ' Drinking causes substantial impairment in my occupational

    performance.

    *

    ' Drinking problem interfere completely with my work

    performance.

    ,

    10 $ow much does your drinking interfere with your social

    functioning& 1s there anything that you don%t or can%t do because of

    your drinking&

    ' Drinking never interferes - 1 can function normally. (

    ' Drinking slightly interferes with my social activities but my

    overall performance is not impaired.

    )

    ' Drinking definitely interferes with my social performance but 1

    can still manage.

    +

    ' Drinking causes substantial impairment in my social

    performance.

    *

    ' Drinking problem interfere completely with my social

    performance.

    ,

    11 1f you were prevented from drinking alcohol when you desired a

    drink how an2ious or upset would you become&

    ' 1 would not e2perience any an2iety or irritation. (

    ' 1 would become only slightly an2ious or irritated. )

    ' The an2iety or irritation would mount but remain manageable. +

    ' 1 would e2perience a prominent and very disturbing increase in

    an2iety or irritation.

    *

    ' 1 would e2perience incapacitating an2iety or irritation. ,

    1' $ow much of an effort do you make to resist consumption of

    alcoholic beverages& /Only rate your effort to resist not your

    success or failure in actually controlling the drinking.0

    ' 4y drinking is so minimal 1 don%t need to actively resist. 1f 1drink 1 make an effort to always resist.

    (

    ' 1 try to resist most of the time. )

    ' 1 make some effort to resist. +

    ' 1 give to almost all drinking without attempting to control it but 1

    do so with some reluctance.

    *

    ' 1 completely and willingly give in to all drinking. ,

    1( $ow strong is the drive to consume alcoholic beverages&

    ' 7o drive. (

    ' Some pressure to drink. )

    ' Strong pressure to drink. + ' 8ery strong drive to drink. *

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    ' The drive to drink is completely involuntary and overpowering. ,

    1) $ow much control do you have over the drinking&

    ' 1 have complete control. (

    ' 1 am usually able to e2ercise voluntary control over it. )

    ' 1 can control it only with difficulty. +

    ' 1 must drink and can only delay drinking with difficulty. *

    ' 1 am rarely able to delay drinking even momentarily. ,

    obsessive compulsive drinking scale 9

    9 4/value ) value +0 ; /value *0; /value ,0; /value 60; /value 0; 4/value 5 value 0

    ; 4/value < value )(0 ; /value ))0; /value )+ 4/value )* value ),0

    1nterpretation:

    ' ma2imum score: ,(

    ' minimum score: (

    ' scores correlate with alcohol craving alcohol dependence and alcohol consumption with

    higher scores indicating more severe affliction

    ' scores after treatment correlate with abstinence =slip= drinking and relapse drinking withabstainers showing lower scores and relapsers showing higher scores

    3eferences:

    nton 3> 4oak D$ ?atham @. The Obsessive Compulsive Drinking Scale: self-rated

    instrument for the "uantification of thoughts about alcohol and drinking behavior. lcohol

    Clin A2p 3es. )

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    >>>18.16.0' The -rief Michiga Alcoholism Tes%

    Overview:

    The Frief 4ichigan lcoholism Test allows rapid assessment of patients for alcohol abuse.

    $ues%ios espose Poi%s

    Do you feel you are a normal drinker& /H or 70 yes (

    no +

    Do friends or relatives think you are a normal drinker& /H

    or 70

    yes (

    no +$ave you ever attended a meeting of lcoholics

    nonymous& /H or 70

    yes 6

    no (

    $ave you ever lost friends girlfriends or boyfriends

    because of drinking& /H or 70

    yes +

    no (

    $ave you ever gotten in trouble at work because of

    drinking& /H or 70

    yes +

    no (

    $ave you ever neglected your obligations your family or

    your work for + or more days in a row because you weredrinking& /H or 70

    yes +

    no (

    $ave you ever had delirium tremens /DTs0 had severe

    shaking heard voices or seen things that weren%t there after

    heavy drinking& /H or 70

    yes +

    no (

    $ave you ever gone to someone for help about your

    drinking& /H or 70

    yes 6

    no (

    $ave you ever been in a hospital because of drinking& /Hor 70

    yes 6

    no (

    $ave you ever been arrested for drunk driving or driving

    after drinking& /H or 70

    yes +

    no (

    1nterpretation:

    ' minimum score: (

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    ' ma2imum score: +>>18.16.0) The Alcohol 2se Disor3ers 43e%ifica%io Tes% 5A2D4T Core $ues%ioaire

    Overview:

    The lcohol Mse Disorders 1dentification Test /MD1T0 core "uestionnaire can be used to

    screen patients for harmful alcohol consumption. 1t was developed by the Jorld $ealth

    OrganiKation and has been used around the world in many languages.

    Components of )(-item "uestionnaire:

    /)0 * "uestions on amount and fre"uency of drinking

    /+0 * "uestions on alcohol dependence

    /*0 , "uestions on problems caused by alcohol

    Parame%er 7i3ig Poi%s

    $ow often do you have a drink containing

    alcohol&

    never (

    monthly or less )

    +-, times a month + +-* times a week *

    , or more times a week ,

    $ow many drinks containing alcohol do you

    have on a typical day when you are drinking&

    ) or + (

    * or , )

    6 or +

    5 to < *

    )( or more ,

    $ow often do you have or more drinks on

    one occasion&

    never (

    less than monthly )

    monthly +

    weekly *

    daily or almost daily ,

    $ow often during the past year have you found

    that you were not able to stop drinking once

    you had started&

    never (

    less than monthly )

    monthly +

    weekly *

    daily or almost daily ,

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    $ow often during the past year have you failed

    to do what was normally e2pected of you

    because of drinking&

    never (

    less than monthly )

    monthly +

    weekly * daily or almost daily ,

    $ow often during the past year have you

    needed a first drink in the morning to get

    yourself going after a heavy drinking session&

    never (

    less than monthly )

    monthly +

    weekly *

    daily or almost daily ,

    $ow often during the past year have you had a

    feeling of guilt or remorse after drinking&

    never (

    less than monthly )

    monthly +

    weekly *

    daily or almost daily ,

    $ow often during the past year have you been

    unable to remember what happened the night

    before because you had been drinking&

    never (

    less than monthly )

    monthly +

    weekly * daily or almost daily ,

    $ave you or someone else ever been in!ured as

    a result of your drinking&

    no (

    yes but not in past year +

    yes during the last year ,

    $as a relative or friend or a doctor or other

    health worker been concerned about your

    drinking or suggested you cut down&

    no (

    yes but not in past year +

    yes during the last year ,

    MD1T score 9

    9 SM4/points for all )( "uestions0

    1nterpretation:

    ' minimum score: (

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    ' ma2imum score: ,(

    ' score I9 indicates a strong likelihood of haKardous or harmful alcohol use.

    7OTA: The MD1T Clinical @rocedure for clinical e2amination of a patient is described in

    the chapter on clinical to2icology.

    3eferences:

    llen E@ Columbus 4 /editors0. ssessing lcohol @roblems. uide for Clinicians and

    3esearchers. 7ational 1nstitute on lcohol buse and lcoholism. 71$

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    /)0 Jhen did you last drink& /Discontinue if the response is =never.=0

    /+0 $ow much do you normally drink each week&

    /*0 $ave you been in hospital more than once because of accidents&

    /,0 $ave any close family members such as a parent spouse brother or sister had drinking

    problems&

    Thinking over the past * months:

    /60 Do you drink before lunch fairly often&

    /0 fter the first glass or two of alcohol do you ever feel a craving for more&

    /50 Do you find you are thinking a lot about alcohol&

    /0 Do you sometimes drink alcohol even against your doctor%s advice&

    /

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    /+*0 $ave you ever deliberately tried to do without any alcohol at all&

    /+,0 $ave you ever been told that your breath smells of alcohol&

    Clinical assessment:

    /+60 @alpable liver.

    /+0 Dupuytren%s contracture.

    /+50 Alevated serum T.

    /+0 Alevated ST.

    where:

    ' >or "uestion + Discontinue if response for men is L 6 and for women L *.

    ' >or "uestion * all types of accidents.

    ' 1n the implementation 1 did not stop the "uestionnaire if the responses to the first + "uestions

    indicated no or low alcohol intake. This was too time consuming to implement but is

    doable.

    Scoring:

    ' response in "uestion + of I9 * for men or I9 ) in women is given ) point.

    ' positive response for "uestions * to + is given ) point.

    total score 9

    9 SM4/points for the +5 "uestions scored0

    1nterpretation:

    ' minimum score: (

    ' ma2imum score: +5

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    ' group of known alcoholics all had a score I9 * and

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    $ow often duo you have a drink

    containing alcohol&

    never (

    monthly or less often (.6

    + to , times per month ).(

    + to * times per week ).6

    , or more times per week +.(

    $ow many drinks containing alcohol do

    you have on a typical day when you are

    drinking&

    ) or + (

    * or , (.6

    6 or ).(

    5 to < ).6

    )( or more +.(

    $ave people annoyed you by criticiKing

    your drinking&

    no (

    yes )$ave you ever felt bad or guilty about

    your drinking&

    no (

    yes )

    $ave you ever had a drink first thing in

    the morning to steady your nerves or get

    rid of a hang-over&

    no (

    yes )

    where:

    ' Other scores use a different scoring range for women when the number of drinks typically

    consumed are considered.

    total score 9

    9 SM4/points for all 6 "uestions0

    1nterpretation:

    ' minimum score: (

    ' ma2imum score: 5

    ' score I9 , is seen in male alcoholics.

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    @erformance:

    ' score of * was 55P sensitive and *P specific for moderate or heavy drinking. The

    overall accuracy was *P.

    ' score of , was 6P sensitive and

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    /,0 A Q eye-opener

    $ues%io espose Poi%s

    $ow many drinks does it take to make you feelhigh& /see modified version below0

    ) Q + (

    I9 * +

    $ave people annoyed you by criticiKing your

    drinking&

    no (

    yes )

    $ave you felt you out to cut down on your

    drinking&

    no (

    yes )

    $ave you ever had a drink first thing in the

    morning to steady your nerves or get rid of ahangover&

    no (

    yes )

    where:

    ' Some "uestionnaires use different alcohol intake levels for men and women. value of I9 *

    seems appropriate for women. higher value /perhaps I9 60 may be necessary for men.

    ' single drink has about (.6 ounces of absolute alcohol.

    ' The =T-CA= comes from + points for T and ) point for CA responses.

    4odified "uestionnaire:

    ' later version /3ussell )

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    1nterpretation:

    ' minimum score: (

    ' ma2imum score: 6

    ' score I9 + was considered positive /sensitivity

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    >>>18.16.08 The CA9 $ues%ioaire for Alcohol Abuse

    Overview:

    The CA "uestionnaire can be used to "uickly screen patients for alcohol abuse. 1t can help

    identify those patients for whom a more in-depth assessment is warranted.

    1tems:

    /)0 C: cut down

    /+0 : annoyed

    /*0 : guilt

    /,0 A: eye-opener

    7OTA: * of the , "uestions are shared with T-CA /C A0. Guestions are also shared with

    TJA and the 6-shot "uestionnaires.

    $ues%io espose Poi%s

    $ave you ever felt you should cut down on your

    drinking&

    no (

    yes )

    $ave people annoyed you by criticiKing your drinking& no (

    yes )

    $ave you ever felt bad or guilty about your drinking& no (

    yes )

    $ave you ever taken a drink first thing in the morning to

    steady your nerves or get rid of a hangover&

    no (

    yes )

    total score 9

    9 SM4/points for all , "uestions0

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    1nterpretation:

    ' minimum score: (

    ' ma2imum score: ,

    ' The higher the score the greater the likelihood of abusing alcohol.

    ' Msing a cutoff I9+ to define a positive test has a sensitivity of (P and specificity of 6P.

    ?imitations:

    ' $aving an =eye opener= strikes me as being pretty specific for alcohol abuse while the other

    * are not. >eeling bad or guilty might be a better measure of neurosis than actual alcohol

    misuse.

    3eferences:

    Fuchsbaum D Fuchanan 3 et al. Screening for alcohol abuse using CA scores and

    likelihood ratios. nn 1nternal 4ed. )

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    Component scores:

    /)0 physician assessment /4?T->0

    /+0 patient self-assessment /4?T-S0

    4?T->: @hysician completed items

    /)0 evidence of liver disease /at least ) finding on physical e2amination 7D at least one

    positive laboratory test0

    /+0 polyneuropathy /only if no other cause is known0

    /*0 delirium tremens /on the present e2amination or previously0

    /,0 alcohol consumption of more than )6( m? /women )+( m?0 of pure alcohol a day at least

    continued over several months.

    /60 alcohol consumption of more than *(( m? /women +,( m?0 of pure alcohol at least once

    a month /alcohol bender0

    /0 foetor alcoholicus /at the time of medical e2amination0

    /50 spouse family members or good friends have sought help because of the alcohol-related

    problems of the patient /e.g. from a physician social worker or other appropriate facilities0

    where:

    ' )6( m? works out to about 6 ounces of alcohol. 1f this is )((P /+(( proof0 alcohol this

    works out to )( drinks. 1f 6(P /)(( proof0 this works out to 6 drinks. Since it says pure

    alcohol 1 will implement it as )( drinks.

    Physicia espose Poi%s

    true ,

    not true (

    4?T-S: @atient completed items

    /)0 4y hands have been trembling a lot lately.

    /+0 1n the morning 1 sometimes have the feeling of nausea.

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    /*0 1 have sometimes to get rid of my trembling and nausea with alcohol.

    /,0 t the moment 1 feel miserable because of my problems and difficulties.

    /60 1t is not uncommon that 1 drink alcohol before lunch.

    /0 fter the first glass or two of alcohol 1 feel a craving for more.

    /50 1 think about alcohol a lot.

    /0 1 have sometimes drunk alcohol even against my doctor%s advice.

    /

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    4?T-> subscore 9

    9 SM4/points for all 5 physician documented items0

    4?T-S subscore 9

    9 SM4/points for all +, patient items0

    total score 9

    9 SM4/points for both subscores0

    1nterpretation:

    ' minimum score: (

    ' ma2imum 4?T-> subscore: +

    ' ma2imum 4?T-S subscore: +,

    ' ma2imum total score: 6+

    Diagosis %o%al score MA:T" subscore

    definite alcoholic I9 )) I9 5

    alcohol problem - )( , -

    @erformance:

    ' 1n the study of Smals et al the 5*P of alcoholic and nonalcoholic patients were correctly

    classified.

    3eferences:

    >euerlein J 3inger C et al. Diagnosis of alcoholism: the 4unich lcoholism Test. Curr

    lcohol. )

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    Smals ?4 van der 4ast 3C et al. lcohol abuse among general hospital inpatients

    according to the 4unich lcoholism Test /4?T0. eneral $ospital @sychiatry. )

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    ' ma2imum score: 6

    ' score I9 + was associated with e2cessive drinking or alcohol abuse.

    ?imitations:

    ' The evaluation of the "uestionnaire involved alcohol abusers and social drinkers. The

    "uestions are sensitive but do not appear to be terribly specific e2cept for the last one

    especially since social drinkers and nondrinkers are more prevalent in society. 1 would

    think adding =after you had been drinking= to the first , "uestions might reduce false

    positives.

    ' n alternative approach would be to add a threshold number to e2ceed. person who

    abuses alcohol would be likely to have been in multiple fights etc.

    ' 1 think that the "uestions might be directed more towards male drinkers than females.

    $ues%io Alcohol

    Abusig

    "ocial

    Dri!ig

    fracture or dislocation P ,)P

    traffic accident 6

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    roups:

    /)0 patients in a family practice

    /+0 social drinker vs outpatient alcohol abuser

    @arameters:

    /)0 history of traumatic in!ury /previous section ranging from ( to 60

    /+0 mean corpuscular volume in femtoliters

    /*0 T in 1M#? transformed to the ?O)(

    /,0 high density lipoprotein cholesterol in mg#d?

    for family practice patient 9

    9 /(.6< R /trauma score00 ; /(.+6 R /4C800 ; /+.< R /?O)(/T000 Q /(.(+ R /$D?C00 Q

    +.*(

    for social drinker vs alcoholic 9

    9 /(.* R /trauma score00 ; /(.) R /4C800 ; /+.(< R /?O)(/T000 ; /(.( R /$D?C00 Q

    ++.(

    probability of e2cessive alcohol use 9

    9 ) # /); A@//-)0 R 00

    3eferences:

    Skinner $ $olt S et al. 1dentification of alcohol abuse using laboratory tests and a history of

    trauma. nn 1ntern 4ed. )

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    >>>18.16.1' The A2D4T Cosump%io 5A2D4TC $ues%ioaire for "creeig of

    Alcohol Abuse

    Overview:

    The MD1T-C "uestionnaire is a brief alcohol screening tool based on the * alcohol

    consumption "uestions of the MD1T "uestionnaire /above0. 1t can help identify patients in

    primary care who should be further evaluated for alcohol usage.

    Guestions:

    /)0 $ow often did you have a drink containing alcohol in the past year&

    /+0 $ow many drinks did you have on a typical day when you were drinking in the past year&

    /*0 $ow often did you have or more drinks on ) occasion in the past year&

    $ues%io espose Poi%s

    $ow often did you have a drink

    containing alcohol in the past year&

    never (

    monthly or less ) + to , times per month +

    + to * times per week *

    , or 6 times per week ,

    or more times per week ,

    $ow many drinks did you have on a

    typical day when you were drinking in the

    past year&

    ( (

    ) or + (

    * or , )

    6 or + 5 to < *

    )( or more ,

    $ow often did you have or more drinks

    on ) occasion in the past year&

    never (

    less than monthly )

    monthly +

    weekly *

    daily or almost daily ,

    where:

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    ' The time frame is during the past year rather than =ever=.

    ' drink was considered a standard drink: can or bottle of beer bottle of wine cooler glass of

    wine one cocktail shot of hard li"uor.

    total score 9

    9 SM4/points for all * "uestions0

    1nterpretation:

    ' minimum score: (

    ' ma2imum score: )+

    ' The higher the score the greater the risk for alcohol misuse.

    ' variety of cutoffs /from I9 * to I9 0 can be used depending on the sensitivity and

    specificity for the different endpoints /heavy drinking dependence at risk drinking0.

    @erformance:

    ' cutoff of I9 , had a sensitivity of P and specificity of 5+P for heaving drinking and#or

    alcohol dependence.

    ' cutoff of I9 6 had a sensitivity of P and specificity of

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    ' s with any screening test the prevalence of problem drinking in the population and the

    selected cut-off will affect how well the test will perform in a clinical setting.

    ' 1 would think that drinking or more times per week should be weighted more than , or 6

    times per week.

    ' 1 wonder if you could get better discrimination by making it a product of the * "uestions

    rather than a sum /range of scores from ( to ,0.

    3eferences:

    Fush ivlahan D3 et al. The MD1T alcohol consumption "uestions /MD1T-C0. n

    effective brief screening test for problem drinking. rch 1ntern 4ed. )>18.16.1( Cri%eria for A%is! Alcohol Dri!ig

    Overview:

    The 7ational 1nstitute on lcohol buse and lcoholism /710 defined criteria for

    identifying a person using alcohol who is =at risk= for progression to a more damaging level

    of consumption. @rimary care providers should encourage a patient with at-risk behavior to

    reduce alcohol consumption.

    @remises:

    /)0 Jomen and elderly males have lower thresholds for alcohol intake than young males /due

    to differences in siKe metabolism and other factors0.

    /+0 4oderate drinking is having a daily alcohol intake up to + standard drinks per day for

    males and ) standard drink for females.

    /*0 veraging consumption over a longer period smooths out day-to-day variability.

    /,0 A2cessive /binge0 drinking involves a daily consumption of a certain number of standard

    drinks.

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    A% is! Dri!ig Male ?@ 6* years

    of age

    Male > 6* years

    of age

    7emale

    average number of

    standard drinks per day

    I + I ) I )

    drinks per week I9 )6 I9 I9

    ma2imum drinks in ) day I9 6 I9 , I9 ,

    3eferences:

    Fierut ?E. Screening and brief interventions for heavy drinking. lcohol 4edical Scholars.

    www.alcoholmedicalscholars.org#brief-int-out.html. ccessed )+#+leming 4 4anwell ?F. Frief interventions in primary care settings. primary treatment

    method for at-risk problem and dependent drinkers. lcohol 3esearch N $ealth. )