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Alcohol Assessment and Intervention - Adult/Pediatric - Inpatient/Ambulatory

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1
Alcohol Assessment and Intervention –
Adult/Pediatric – Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ....................................................................................................................................... 3
SCOPE ................................................................................................................................................................ 3
METHODOLOGY ................................................................................................................................................. 4
DEFINITIONS ...................................................................................................................................................... 5
INTRODUCTION.................................................................................................................................................. 6
RECOMMENDATIONS ......................................................................................................................................... 7
Screening for Alcohol Use ..................................................................................................................................... 7
Brief Intervention .................................................................................................................................................. 8
Further Assessment and Referral to Treatment .................................................................................................... 9
Follow Up and Management .............................................................................................................................. 10
Table 2. Pharmacotherapy Options for Alcohol Dependence 39-41 ...................................................................... 11
UW HEALTH IMPLEMENTATION ........................................................................................................................ 12
APPENDIX A. EVIDENCE GRADING SCHEME(S) ................................................................................................... 14
APPENDIX B. ..................................................................................................................................................... 15
APPENDIX C. ..................................................................................................................................................... 16
APPENDIX D. COMMUNICATION TIPS FOR ASKING PATIENTS ABOUT ALCOHOL USE .......................................... 17
APPENDIX E. DSM-5 CRITERIA FOR ALCOHOL USE DISORDER ............................................................................. 18
APPENDIX F. INPATIENT QUALITY METRICS ....................................................................................................... 19
APPENDIX G. HEDIS MEASURES FOR PATIENTS WITH A NEW AOD DIAGNOSIS ................................................... 21
REFERENCES ...................................................................................................................................................... 22
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Contact for Content:
Randall Brown, MD, PhD, FASAM ± Department of Family Medicine
Phone Number: (608) 263-6558
Email Address: randy.brown@fammed.wisc.edu

Contact for Changes:
Janna Lind, MSN ± Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6695
Email Address: jlind@uwhealth.org

Coordinating Team Members:
Richard L. Brown, MD, MPH ± Family Medicine
James Bigham, MD ± Family Medicine
Aleksandra Zgierska, MD, PhD ± Family Medicine
Karen Loomans, MD ± General Internal Medicine
Paula Cody, MD ± Pediatrics (Adolescent Medicine)
Troy Kleist, MD ± Pediatrics
Laura Kwitek, NP ± Obstetrics
Alexis Eastman, MD ± Geriatric Medicine
Michael Waupoose, MD ± Psychiatry- General
Lynnda Zibell-Milsap, MS, RN ± Senior Clinical Nurse Specialist Psychiatric Liaison
Nathan Whitman, DNP, RN, ± Clinical Nurse Specialist Psychiatric Liaison
Rebecca Turpin, MA ± Injury Prevention Coordinator
Susan Mindock ± Center for Treatment of Addictive Disorders
Kathy Chambers, MA, LPC ± Patient Resources
Debra Gatzke, RN, MS ± Patient Resources
Cheryl DeVault, BSN, RN, OCN ± Family Medicine ± General
Linda Kiefer, RN ± Family Medicine ± General
Alana Winchel, RN ± Pediatrics ± General
Carin Endres, PharmD ± Drug Policy Program
Richard Deming, MD ± Swedish American Health System
Kimberly Hein-Beardsley ± Unity Health Insurance
Phillip Bain, MD ± Internal Medicine (SSM Health)
Megan Mahaffey, MD ± Pediatrics (SSM Health)
Cheryl Lampman, RN ± Physicians Plus Corporation (PPIC)
Jen Grice, PharmD ± Center for Clinical Knowledge Management (CCKM)
5\OH\�2¶%ULHQ�± Center for Clinical Knowledge Management (CCKM)
Lindsey Spencer, MA ± Center for Clinical Knowledge Management (CCKM)
Brian Sharp, MD ± Emergency Department
Jayne McGrath, CNS ± Emergency Department

Review Individuals/Bodies:
Cynthia Green, MSW ± Adolescent Alcohol/Drug Assessment Intervention Program (AADAIP)

Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 11/17/2016)

Release Date: November 2016 | Next Review Date: November 2018
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Executive Summary
Guideline Overview
7KH������1,$$$�3K\VLFLDQ¶V�*XLGH��WKH�2015 VA/DoD Clinical Practice Guideline, as well as
the 2016 American Academy of Pediatrics Clinical Report served as the primary outline to this
document.1-3

Key Revisions 2016 Periodic Review
1. Recommendations removed for patients known to be pregnant
2. Recommendations added for emergency department and hospital inpatient settings

Key Practice Recommendations
1. Screening should take place at least annually in the primary care setting (UW Health Very low
quality evidence, weak/conditional recommendation), with each admission in the Emergency
Department (UW Health Low quality evidence, weak/conditional recommendation), and with each
admission in the inpatient hospital setting.4,5 (UW Health Low quality evidence, weak/conditional
recommendation)
2. Adolescent patients should be screened for alcohol and drug use using Part A of the
CRAFFT screening tool (version 2.0).3,6-8 (UW Health Low quality evidence, strong
recommendation) If the patient responds to DQ\�TXHVWLRQ�ZLWK�D�QXPEHU�JUHDWHU�WKDQ�³��´�DOO�6
CRAFFT questions should be asked. The CAR question should be asked regardless of
patient response to Part A.
3. UW Health recommends using the Alcohol Use Disorders Identification Test ± Consumption
(AUDIT-C) to screen for alcohol misuse in non-pregnant adults.9-12 (UW Health Low quality
evidence, strong recommendation)
4. Adult patients who screen positive for unhealthy alcohol use (AUDIT-C score of 3 to 7 for
men over 65 years and all adult women; 4 to 7 for men 18 to 65 years) should receive a
brief counseling intervention.13-15 (UW Health Moderate quality evidence, weak/conditional
recommendation)
5. Adult patients who are likely to have an alcohol use disorder (AUDIT-C score of 8 or greater)
should receive further assessment and/or a referral to treatment with a specialist in alcohol
and drug related issues.5,16 (UW Health Moderate quality evidence, weak/conditional
recommendation)

Companion Documents
1. Adolescent Alcohol Screening and Intervention Algorithm
2. Adult Alcohol Screening and Intervention Algorithm
3. Communication Tips for Asking Patients About Alcohol Use
4. Table 1. NIAAA Recommended Drinking Limits
5. Table 2. Pharmacotherapy Options for Alcohol Dependence

Scope
Disease/Condition(s): Risky alcohol use (hazardous drinking), Alcohol Use Disorder (alcohol
abuse and/or dependence)

Clinical Specialty: Ambulatory Nursing, Inpatient Nursing, Internal Medicine, Family Medicine,
Addiction Medicine, Emergency Department

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Intended Users: Registered Nurses, Licensed Practical Nurses, Medical Assistants, Social
Workers, Behavioral Health Specialists, Health Education Specialists, Pharmacists, Physicians,
Advanced Practice Providers

Objective(s): To provide evidence-based recommendations on alcohol use screening, brief
intervention, referral to treatment, and pharmacotherapy. This guideline does not include
recommendations pertaining to alcohol withdrawal.

Target Population: Non-pregnant adolescent (10-17 years) and adult (18 years and older)
patients without a current diagnosis of alcohol use disorder. Recommendations regarding
pregnant patients are not included in this guideline.

Interventions and Practices Considered:
ξ Screening
ξ Brief intervention
ξ Referral to treatment
ξ Pharmacotherapy

Major Outcomes Considered:
ξ Reduction in risky drinking (consumption greater than daily and weekly limits for age and
gender)
ξ Reduction in alcohol abuse and dependence
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities:
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Studies show variable differences between ethnic and racial groups in the amount of alcohol
consumption and associated health burden, including risk for injury and deaths attributable to
alcohol. Studies consistently show Native Americans carry the greatest burden with over 20%
of deaths attributable to alcohol. Asians appear to carry the lowest burden.1,17-19 In studies which
show greater levels of alcohol-related harm in Hispanics and Blacks as compared to Whites, the
differences can be often be accounted for by socioeconomic status.20-22 Racial and ethnic
disparities have been noted in outpatient and residential substance use disorder treatment
completion, with Hispanics and Blacks completing treatment less often than Whites. Again,
differences are mitigated when level of economic resources are taken into account.23-25
Definitions
Table 1. NIAAA Recommended Drinking Limits1
For healthy men up to age 65
ξ No more than 4 drinks in a day AND
ξ No more than 14 drinks in a week

For healthy women, and healthy men over age 65
ξ No more than 3 drinks in a day AND
ξ No more than 7 drinks in a week


ξ Standard drink: A standard drink in the United States is any drink that contains about 14
grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons). Below are U.S. standard
drink equivalents. These are approximate, since different brands and types of beverages
vary in their alcohol content.
One standard drink = 12 oz. regular beer = 8-9 oz. malt liquor = 5 oz. table wine = 1.5 oz.
80-proof hard liquor.1

Figure 2. NIAAA Standard Drink Chart1


ξ Alcohol Use Disorder: A problematic pattern of alcohol use leading to clinically significant
impairment or distress, as manifested by at least two diagnostic criteria occurring within a
12-month period.26 (See Appendix E)
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ξ At Risk Use: Consuming the equivalent of more than 4 standard drinks in a day or more
than 14 in a week, for men and the equivalent of more than 3 standard drinks in a day or
more than 7 in a week for women who do not meet criteria for alcohol dependence or abuse.
6RPH�OLWHUDWXUH�DOVR�XVHV�WKH�WHUP�³KD]DUGRXV�GULQNLQJ´�IRU�GULQNLQJ�WKDW�UXQV�WKH�ULVN�RI�
causing serious problems.
ξ Harmful Drinking (Alcohol Abuse): Drinking amounts that cause serious problems. These
problems include motor vehicle crashes, physical health and/or mental health problems,
violence, injuries, unsafe sex, and serious issues in areas of life such as work, school,
family, social relationships, and finances.

Introduction
Excessive alcohol consumption accounted for nearly 1 in 10 deaths and over 1 in 10 years of
potential life lost among working-age adults in the United States between 2006-2010.27 In 2015,
it was estimated that 24% of U.S. adolescents aged 12-17 years used alcohol or drugs within
the previous year, and 5.0% met criteria for a substance-related disorder.28 According to the
2015 Dane County Youth Report, 34.8% of high school youth and 8.1% of middle school youth
said they drank alcohol in the past 12 months.29


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Recommendations
Screening for Alcohol Use
Screening of alcohol use status is the first critical step in determining problem drinking. For tips
on how to approach alcohol screening with a patient, see Appendix D. Screening should take
place at least annually in the primary care setting (UW Health Very low quality evidence,
weak/conditional recommendation), with each admission in the Emergency Department (UW Health
Low quality evidence, weak/conditional recommendation), and with each admission in the inpatient
hospital setting.4,5 (UW Health Low quality evidence, weak/conditional recommendation) Universal
screening for alcohol use and an intervention for those who screen positive is required for all
injured patients at Level I trauma centers.30 Patients with a current diagnosis of alcohol use
disorder (AUD) or who are exhibiting symptoms highly indicative of an AUD do not need to be
screened. (UW Health Low quality evidence, strong recommendation)

Adolescents and Alcohol Use
The CRAFFT (Car, Relax, Alone, Forget, Family/Friends, Trouble) is a validated tool to screen
adolescents for risky drinking and drug behaviors. Adolescent patients should be screened for
alcohol and drug use using Part A of the CRAFFT (version 2.0).3,6-8 (UW Health Low quality
evidence, strong recommendation) If the patient responds to any question with a number greater
WKDQ�³��´�DOO�6 CRAFFT Part B questions should be asked. The CAR question should be asked
regardless of patient response to Part A.

3DWLHQWV�ZLWK�OHVV�WKDQ�WZR�³\HV´�DQVZHUV�RQ�WKH�&5$))7�VKRXOG�UHFHLYH�D�EULHI�FRXQVHOLQJ�
intervention.3,7 (UW Health Low quality evidence, weak/conditional recommendation) A score of two or
PRUH�³\HV´�DQVZHUV�VXJJHVW�D�VHULRXV�SUREOHP�DQG�QHHG�IRU�IXUWKHU�DVVHVVPHQW��3DWLHQWV�ZLWK�
WZR�RU�PRUH�³\HV´�DQVZHUV�RQ�WKH�&5$))7�VKRXOG�UHFeive a brief intervention and a referral to
treatment with a specialist in alcohol and drug related issues.3,7 (UW Health Low quality
evidence, weak/conditional recommendation)

Adults and Alcohol Use
The United States Preventive Services Task Force (USPSTF) recommends that clinicians
screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky
or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.5
(USPSTF B Recommendation) UW Health recommends using the Alcohol Use Disorders
Identification Test ± Consumption (AUDIT-C) to screen for alcohol misuse in non-pregnant
adults.9-12 (UW Health Low quality evidence, strong recommendation) The AUDIT-C includes the first
three questions of the full AUDIT screening tool.

Adult patients who screen positive for unhealthy alcohol use (AUDIT-C score of 3 to 7 for men
over 65 years and all adult women; 4 to 7 for men 18 to 65 years) should receive a brief
counseling intervention.13-15 (UW Health Moderate quality evidence, weak/conditional recommendation)
It is important to note that even low or moderate drinking is risky for some patients in certain
clinical situations (e.g. pregnancy, taking warfarin), and these patients should be advised to not
drink at all.1,2,31 (UW Health Moderate quality evidence, weak/conditional recommendation)

Adult patients who are likely to have an alcohol use disorder (AUDIT-C score of 8 or greater)
should receive further assessment and/or a referral to treatment with a specialist in alcohol and
drug related issues.5,16 (UW Health Moderate quality evidence, weak/conditional recommendation)

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Clinicians may consider using the entire AUDIT screening tool to evaluate adult patients for
potential negative health or social consequences associated with drinking.10,32 (UW Health
Moderate quality evidence, weak/conditional recommendation) This information may be helpful when
conducting the brief intervention or when discussing referral to treatment with the patient.
Brief Intervention
Motivating patients to reduce or stop drinking is the essence of a brief intervention. The
intervention includes providing feedback on alcohol use and harms, identification of high risk
situations for drinking and coping strategies, as well as motivating patients to develop a
personal plan to reduce drinking. A brief intervention can be as short as five minutes in the
primary care clinical setting.33

Clinicians may consider using the entire AUDIT screening tool to evaluate adult patients for
potential negative health or social consequences associated with drinking.10,32 (UW Health
Moderate quality evidence, weak/conditional recommendation) The SDWLHQW¶V�UHVSRQVHV�PD\�SURYLGH�
LQVLJKW�LQWR�WKH�SDWLHQW¶V�YDOXHV�DQG�FRQFHUQV��ZKLFK�can be incorporated into the brief
intervention.

Below are specific statements and messages clinicians may want to utilize with patients who
use alcohol above recommended limits.

1. Direct feedback:
³$V�\RXU�FOLQLFLDQ�,�DP�FRQFHUQHG�DERXW�KRZ�PXFK�\RX�GULQN�DQG�KRZ�LW�LV�DIIHFWLQJ�\RXU�KHDOWK�´
³problems, especially accidents, LQMXULHV�RU�D�ZRUVHQLQJ�RI�\RXU�KHDOWK�SUREOHPV�´

2. Discuss how their alcohol use is affecting their health:
³$V�\RXU�clinician I am concerned about how your alcohol use is affecting our ability to treat your
___________ (mention additional conditions, e.g��K\SHUWHQVLRQ��GLDEHWHV��GHSUHVVLRQ��´
³$OO�RI�\RXU�SUHYLRXV�VXLFLGH�DWWHPSWV�ZHUH�DVVRFLDWHG�ZLWK�KHDY\�GULQNLQJ�´
³
NOTE: If a patient reports excessive daily drinking, provide brief anticipatory guidance for
possible withdrawal symptoms and consider providing the patient with educational materials.
(UW Health Low quality evidence, strong recommendation)

3. Negotiate and set goals:
³$V�\RXU�clinician, I would recRPPHQG�IRU�\RX�WR�>DEVWDLQ�IURP�RU�UHGXFH@�\RXU�GULQNLQJ�´��LI�WKH�
clinician recommends abstaining, such as in alcohol addiction��LW�LV�EHQHILFLDO�WR�DGG��³+RZHYHU��
if you are unable to abstain, even if you reduce your drinking it will be beneficial for yoXU�KHDOWK´�
³:KDW�GR�\RX�WKLQN�DERXW�FXWWLQJ�GRZQ�WR�WKUHH�GULQNV���WR���WLPHV�SHU�ZHHN"´
³&DQ�\RX�UHGXFH�\RXU�drinking IRU�WKH�QH[W�PRQWK"´

4. Behavioral modification strategies:
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9



³7KHUH�DUH�VRPH�VLWXDWLRQV�ZKHQ�SHRSOH�GULQN�DQG�VRPHWLPHV�ORVH�FRQWURO�RI�their drinking.
These situations include going out to dinner with friends, having difficulty sleeping, or during
WLPHV�RI�VWUHVV��/HW¶V�WDON�DERXW�ZD\V�\RX�FDQ�DYRLG�WKHVH�VLWXDWLRQV�´
³&DQ�\RX�LGHQWLI\�D�IDPLO\�PHPEHU�RU�D�IULHQG�ZKR�FDQ�KHOS�\RX"´
³:KDW�DUH�WKH�WKLQJV�\RX�OLNH�DERXW�GULQNLQJ"´
³:KDW�DUH�VRPH�RI�WKH�WKLQJV�\RX�GRQ¶W�OLNH�DERXW�\RXU�DOFRKRO�XVH"´
³/HW¶V�SUDFWLFH�ZKDW�\RX�ZLOO�VD\�WR�\RXU�IULHQGV�RU�IDPLO\�PHPEHUV�ZKHQ�WKH\�RIIHU�\RX�D�GULQN�´

5. Self-help directed bibliotherapy : (when available)
³,�ZRXOG�OLNH�\RX�WR�UHYLHZ�WKLV�ERRNOHW�RQ�ZD\V�WR�UHGXFH�\RXU�DOFRKRO�XVH�DQG�EULQJ�LW�ZLWK�\RX�
WR�RXU�QH[W�YLVLW�´
³,W�ZRXOG�EH�YHU\�KHOSIXO�LI�\RX�ZRXOG�FRPSOHWH�VRPH�RI�WKH�H[HUFLVHV�LQ�WKLV�JXLGH�´

6. Follow-up and reinforcement
³,�ZRXOG�OLNH�\RX�WR�UHWXUQ�WR�VHH�PH�LQ�RQH�PRQWK�WR�VHH�KRZ�\RX�DUH�GRLQJ�´
³6RPHRQH�IURP�P\�RIILFH�ZLOO�FDOO�\RX�LQ�WZR�ZHHNV�WR�FKHFN�LQ�ZLWK�\RX�´
³3OHDVH�PDNH�DQ�DSSRLQWPHQW�WR�VHH�PH�LQ���ZHHNV�´
³6RPHWLPHV�SHRSOH��GHVSLWH�EHVW�LQWHQWLRQV��DUH�QRW�DEOH�WR�DFKLHYH�WKH goals they set for
WKHPVHOYHV��,�KRSH�\RX¶OO�EH�VXFFHVVIXO��EXW�LI�\RX�KDYH�SUREOHPV�ZLWK�LW��SOHDVH�FRPH�DQG�WDON�
WR�PH��DQG�ZH¶OO�VWDUW�IURP�WKHUH�´
As with most kinds of behavioral therapy, Brief Intervention works best when delivered in a non-
judgmental, caring, empathetic manner.

Further Assessment and Referral to Treatment
$GROHVFHQW�SDWLHQWV�ZLWK�WZR�RU�PRUH�³\HV´�DQVZHUV�RQ�WKH�&5$))7�VKRXOG�UHFHLYH�D�EULHI�
intervention and a referral to treatment with a specialist in alcohol and drug related issues.3,7
(UW Health Low quality evidence, weak/conditional recommendation)

Adult patients who are likely to have an alcohol use disorder (AUDIT-C score of 8 or greater)
should receive further assessment and/or a referral to treatment with a specialist in alcohol and
drug related issues.5,16 (UW Health Moderate quality evidence, weak/conditional recommendation)

Clinicians may consider using the entire AUDIT screening tool to evaluate adult patients for
potential negative health or social consequences associated with drinking.10,32 (UW Health
Moderate quality evidence, weak/conditional recommendation) This information may be helpful to
further assess the patient or when discussing referral to treatment.

The following questions are included as examples for clinicians to further assess a potential
alcohol problem via a semi-structured interview following use of the previously described
assessment tools.



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Clinician-Patient Interview:
1. Have you ever missed an important family event due to your drinking? (i.e., one of your
FKLOGUHQ¶V�ELUWKGD\V��D�VSRUWLQJ�HYHQW��RU�D�VFKRRO�DFWLYLW\"�
2. Has anyone ever asked you to cut down or stop your drinking?
3. Have you ever tried to cut down on your drinking for a while?
4. What made you cut down?
5. Have you ever driven a car while under the influence of alcohol?
6. Has drinking affected your work or school?
7. :KDW�DUH�VRPH�WKLQJV�\RX�OLNH�DERXW�GULQNLQJ"�:KDW�GRQ¶W�\RX�OLNH"
8. How many risky drinking days have you had in the last month? (Risky defined as more
than 4 (women, men > 65 yrs.) or 5 (men< 65 yrs.) drinks/day).1

Based upon the answers provided during the interview and on the formal assessment, a
provider may consider establishing a diagnosis for alcohol use disorder (see Appendix E). It
may also be beneficial to consider adding a diagnosis to the problem list, to alert colleagues to
the potential for additional health complications, and for higher risk of misuse of potentially
addictive prescription medications. (UW Health Low quality of evidence, strong recommendation)

NOTE: Following diagnosis, patients are subject to follow requirements established by the
Healthcare Effectiveness Data and Information Set (HEDIS) for initiating and engaging patients
in treatment. For more information, see Appendix G.

Follow Up and Management
Patients in all clinical settings who do not drink or who have a negative screen for alcohol
misuse should be given positive reinforcement (verbal). Patients may be encouraged to
continue to abstain or drink below recommended limits (see Table 1). (UW Health Very low quality
evidence, weak/conditional recommendation)

Patients who have received a brief intervention should have follow up with primary care in about
4 weeks. (UW Health Very low quality evidence, weak/conditional recommendation)

The primary care clinic should follow up with patients who have received a referral for treatment
in about 2 to 8 weeks. If the patient has NOT started with the referred treatment, for whatever
reason, pharmacotherapy and/or behavioral management in primary care should be considered.
(UW Health Very low quality evidence, weak/conditional recommendation)

Pharmacotherapy
Medications may be used to assist adult patients in their recovery from alcohol dependence,
whether or not they are receiving specialty-based treatment.34-38 Use is indicated for patients
motivated to reduce alcohol intake. (UW Health High quality evidence, strong recommendation) The
following table (Table 2) provides information on the contraindications, adverse effects, and
recommended doses for FDA-approved medications.39-41 There is insufficient evidence to
recommend a particular medication as a first line agent; therefore, treatment should be
individualized based on patient-specific factors.2,42 (UW Health Very low quality evidence,
weak/conditional recommendation) Given its relative lack of efficacy and its toxicity, disulfiram
should be considered only after an inadequate response to other agents.42 (UW Health Moderate
quality evidence, weak/conditional recommendation) Witnessed dosing by an appropriate close
personal contact or specialist treatment provider is generally preferable to ensure adherence.43
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11
Table 2. Pharmacotherapy Options for Alcohol Dependence 39-41
Medication Contraindications/ Precautions
Adverse
Effects Dosage Initiation Discontinuation
Naltrexone
(ReVia® - tablet)
(Vivitrol® -
extended release
microemulsion -IM
administration)
- Concurrent use of opioids (use in the
last 7-10 days)
- Opioid withdrawal
- Pregnancy Category C
- Active liver disease
Nausea, headache,
dizziness,
abdominal
discomfort,
increased liver
function tests and
CK, injection site
reactions
Tab ± 50 mg PO daily
If at increased risk for side
effects (e.g. active drinker,
elderly), consider starting at
25 mg and taper up.
Injection ± 380 mg IM every 28
days
3+ days abstinence from
alcohol recommended
but not required

Initial LFTs and urine
drug screen
Duration: 3-12 months.
Clinical response may allow
for continued use.
No withdrawal effects; no
need to taper
Acamprosate
(Campral®)
- Severe renal impairment (creatinine
clearance < 30 mL/min)
- Suicide ideation
- Pregnancy Category C
- Use with caution in elderly patients
Diarrhea, insomnia,
anxiety, fatigue
333mg TID for 3-5 days
(initiation)

666 mg PO three times daily
(maintenance)
Most efficacious with 7
days abstinence

Initial renal function tests
Duration: > 12 months

No withdrawal; no need to
taper
Topiramate
(Topamax®)

(Not FDA-
approved for
alcohol use
disorder)
- Conditions or medications that
predispose to metabolic acidosis
- Psychiatric or behavior disturbances
- Pregnancy Category D
Dizziness, cognitive
impairment,
anorexia, weight
loss, somnolence,
abnormal serum
bicarbonate
Initiate at 50 mg daily and
increase dose over several
weeks to 150 mg twice daily
Initiate at 50 mg daily,
increase by 50 mg
weekly to 100 mg twice
daily. If cravings persist,
doses can be titrated up
to 150 mg twice daily.
Taper by decreasing daily
dose by 50 mg each week,
unless safety considerations
warrant more rapid
withdrawal.
Gabapentin
(Neurontin®)

(Not FDA-
approved for
alcohol use
disorder)
- Use with caution in severe renal
impairment, elderly as dosage
adjustments may be needed
- Pregnancy Category C
Somnolence,
dizziness,
peripheral edema,
Therapeutic benefit seen at
1600-2400 mg/day in divided
doses
Initiate at 300 mg, 3 x
daily. Titrate to 1200 mg
total daily dose by day 5,
in divided doses as
tolerated.
Could taper by 25% weekly.
Clinical response may allow
for continued use.
Disulfiram
(Antabuse®)
- Myocardial disease
- Alcohol-containing cough
preparations
- Psychosis
- Pregnancy Category B2 (Australian)
- Use with caution in elderly patients
- Concurrent metronidazole
- Active liver disease
Dermatitis, flushing
with alcohol
ingestion, increase
in liver function
tests, metallic taste,
peripheral
neuropathy
500 mg PO daily for 1 ± 2
weeks, then 250 mg daily
12+ hours abstinence
and/or BAC = 0

Baseline LFTs, urine
HCG

ECG if clinically indicated
Duration: Up to 20 months

No withdrawal; no need to
taper

Reaction with alcohol up to
2 weeks after
discontinuation

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12
UW Health Implementation
Potential Benefits:
ξ Help patients recognize problems or potential problems related to their drinking.
ξ Provide encouragement for positive change and belief in the ability to change
ξ Reduce harms related to alcohol use, including traumatic injuries, medical problems, and
social/relationship/employment problems

Potential Harms:
ξ Incorrect identification of patients who do not have risky behaviors.
ξ Failure to properly identify all patients who may be abusing alcohol.

Pertinent UW Health Policies & Procedures
1. UWHC Policy 10.0: Screening of Emergency Department Patients

Patient Resources
1. Health Facts For You #7628 ± Cutting Back on Your Drinking
2. Health Facts For You #5717 ± Older Adults and Alcohol Abuse
3. Health Facts For You #4611 ± Alcohol and Drug Abuse: A Guide to Community Services
4. Healthwise ± Alcohol Use: Teen: General Info
5. Healthwise ± Alcohol Abuse: Your Teen: General Info
6. Healthwise ± Alcohol Abuse and Addiction: Teen: General Info
7. Healthwise ± Alcohol and Drug Problems
8. Healthwise ± Alcohol, Drug, or Poison Ingestion
9. Health Information ± Alcohol Abuse, Teen
10. Health Information ± Alcohol Abuse: Dealing with teen substance use
11. Health Information ± Alcohol and Drug Problems
12. Health Information ± Alcohol Abuse and Dependance
13. Health Information ± Alcohol Abuse, Do You Have a Drinking Problem Interactive Tool
14. Health Information ± Alcohol Abuse: Other Health Problems That May Occur
15. Health Information ± Alcohol and Heart Disease
16. Health Information ± Alcohol Problems: How to Stop Drinking
17. Kids Health ± Kids and Alcohol (Parents)
18. Kids Health ± Alcohol (Teens)
19. Kids Health - Binge Drinking (Teens)
20. Kids Health ± I Think I May Have a Drinking/Drug Problem. What Should I Do? (Teen)

Guideline Metrics
1. See Appendix F and Appendix G for required metrics
2. Number of patients being screened in the ambulatory setting using the AUDIT-C
3. Number of brief interventions performed in the ambulatory setting
4. Number of referrals made in the ambulatory setting to a specialist in alcohol and drug issues

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.

Best Practice Alerts (BPA)
UWIP B AUDIT-C AODA CONSULT NEEDED ADULT [3000850]
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13
UWED B FLOWSHEET AUDIT-C ADDING FOLLOW UP ED QUESTION TO DISCHARGE
INFO [181181] ± adds an educational follow-XS�TXHVWLRQ�WKDW¶V�QRW�VKRZQ�WR�WKH�HQG�XVHU
UWIP B ADD CARE PLAN FOR AUDIT-C SCORE GREATER THAN 3 [3000852]
UWIP B ADD PATIENT ED FOR AUDIT-C SCORE GREATER THAN 3 [3000180]

EAP/ERX Records
Consult Addictive Disorders (Inpatient) [CON0003]

Smart Text
ARI GUIDLINES - BRIEF INTERVENTION 3012521
AODA ASSESSMENT [3000333]


Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
LQWHQGHG�WR�UHSODFH�D�FOLQLFLDQ¶V�MXGJPHQW�RU�WR�Hstablish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

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14
Appendix A. Evidence Grading Scheme(s)

Figure 1. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.

USPSTF Grades for Recommendations
Grade Definition
A The USPSTF recommends the service. There is high certainty that the net benefit is
substantial.
B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
C
The USPSTF recommends selectively offering or providing this service to individual
patients based on professional judgment and patient preferences. There is at least
moderate certainty that the net benefit is small.
D The USPSTF recommends against the service. There is moderate or high certainty that
the service has no net benefit or that the harms outweigh the benefits.
I Statement
The USPSTF concludes that the current evidence is insufficient to assess the balance of
benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and
the balance of benefits and harms cannot be determined.

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15
Appendix B.
ADOLESCENT Alcohol
Screening and Intervention
Algorithm
Screen for alcohol misuse
Primary Care: Screen new patients and at Least Annually
Hospital Inpatients: Every Admission
ED: Every Admission
CRAFFT 2.0, Part A: 3 Question Pre-Screen
During the past 12 months, on how many days did you:
1. Drink more than a few sips of beer, wine, or any drink containing alcohol? Say “0” if none.
2. Use any marijuana (pot, weed, hashish, or in foods) or “synthetic marijuana” (like “K2” or “Spice”)? Say “0” if none.
3. Use anything else to get high? (like other illegal drugs, prescription or over-the-counter medications, and things you
sniff or “huff”)? Say “0” if none.
Ask all six
CRAFFT
questions
Patient Response
“0” for all questions?
Complete CAR
question of
CRAFFT Assessment
Patient
Response
“Yes”?
Screening complete
Yes No
Provide patient
education
regarding safe
driving habits.
2 or more YES
answers?
Provide brief
intervention
Yes
Give positive
reinforcement,
encourage to continue
to not use
No
Provide brief intervention and Refer to specialist
in alcohol/drug related issues*
*Addiction Medicine consult suggested for inpatients.
AUD diagnosis and/or referral for additional outpatient
treatment may be made by consulting service.
Follow up with Primary
Care in about 4 weeks
Follow up with Primary Care in
about 2-8 weeks
Did patient begin
treatment with
referred services?
Consider pharmacotherapy
and/or behavioral
management in Primary Care
Follow up per PCP
discretion
No
Yes
Yes
No
Last Reviewed Nov 2016
Alcohol – Pediatric/Adult –
Ambulatory/Inpatient
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16
Appendix C.

Screen for alcohol misuse
using the AUDIT-C
Primary Care: Screen New Patients and at Least Annually
Hospital Inpatients: Every Admission
ED: Every Admission
AUDIT-C
Score
0-2
Men over 65 years
and all women
8-12
Men and women
Screening complete
Provide brief
intervention (BI)
ADULT Alcohol
Screening and
Intervention
Algorithm
Give positive reinforcement.
Advise to continue to drink below
recommended limits*:
Men age 65 years or younger: ≤4
standard drinks per day; ≤ 14 per week
Men over 65 year and all women: ≤ 3
drinks per day; ≤ 7 drinks per week
*Abstinence should be recommended to
some patients in certain clinical
situations (e.g., pregnancy, warfarin)
0-3
Men age 65 years
or younger
3-7
Men over 65 years
and all women
4-7
Men age 65 years
or younger
Low Risk
High Risk
Refer to specialist in alcohol/drug
related issues*
*Addiction Medicine consult suggested for
inpatients.
AUD diagnosis and/or referral for additional
outpatient treatment may be made by
consulting service.
Likely Alcohol Use Disorder
Follow up with Primary
Care in about 4 weeks
Follow up with Primary Care in
about 2-8 weeks
Did patient begin
treatment with
referred services?
Consider pharmacotherapy
and/or behavioral
management in Primary Care
Follow up per PCP
discretion
Last Reviewed Nov 2016
Alcohol – Pediatric/Adult –
Ambulatory/Inpatient
No
Yes


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17
Appendix D. Communication Tips for Asking Patients About Alcohol Use

Alcohol use is related to many serious health concerns, ranging from car accidents to cancer to cardiovascular
disease. If we can identify those with risky or harmful alcohol use, we may be able to help patients reduce their
drinking or get the help they need.

6RPH�FOLQLFLDQV�IHHO�XQFRPIRUWDEOH�DVNLQJ�DERXW�DOFRKRO�XVH��HVSHFLDOO\�LI�LW�LV�XQUHODWHG�WR�WKH�SDWLHQW¶V�UHDVRQ�IRU�
visit or current health concerns. Most patients do not mind answering the alcohol screening questions. If you like, you
may consider introducing the topic in one of the following ways:

³:H�VFUHHQ�DOO�RXU�SDWLHQWV�IRU�DOFRKRO�XVH�EHFDXVH�LW�LV�DQ�LPSRUWDQW�IDFWRU�LQ�\RXU�KHDOWK�´�

³0D\�,�DVN�\RX�D�IHZ�TXHVWLRQV DERXW�\RXU�DOFRKRO�XVH"´

³,¶P�JRLQJ�WR�DVN�\RX�D�IHZ�TXHVWLRQV�DERXW�DOFRKRO�XVH��,W�ZRQ¶W�WDNH�ORQJ�´

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18

Appendix E. DSM-5 Criteria for Alcohol Use Disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) considers the following
diagnostic criteria (manifested by at least two of the following within a 12-month period)
indicative of an alcohol use disorder26:
1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover
from its effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or
home.
6. Continued alcohol use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or reduced because of
alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol 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 alcohol.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of alcohol to achieve intoxication or desired
effect.
b. A markedly diminished effect with continued use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the
criteria set for alcohol withdrawal).
b. Alcohol (or a closely related substance, such as benzodiazepine) is taken to relieve
or avoid withdrawal symptoms.

Mild: Presence of 2-3 symptoms
Moderate: Presence of 4-5 symptoms
Severe: Presence of 6 or more symptoms.



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19
Appendix F. Inpatient Quality Metrics
The following metrics are from the Joint Commission Hospital Inpatient Quality
Reporting Program Specifications Manual.

SUB-1: “$OFRKRO�8VH�6FUHHQLQJ´
ξ Description: Psychiatric inpatients screened within the first 3 days of admission using a
validated screening questionnaire for unhealthy alcohol use.
ξ Numerator: The number of psychiatric inpatients who were screened for alcohol use
using a validated screening questionnaire for unhealthy drinking within the first 3 days of
admission.
ξ Denominator: The number of psychiatric hospitalized patients 18 years of age and
older.
ξ ABSTRACTOR COMMENTS:
o We currently use the Audit-C screening for this measure.
o Documentation of cognitive impairment throughout the first 3 days following
admission will exclude the case from the measure.
 Temporary cognitive impairment due to acute substance use (e.g.
overdose or acute intoxication) will not exclude the case.
SUB-2 “$OFRKRO�8VH�%ULHI�,QWHUYHQWLRQ�3URYLGHG�RU�2IIHUHG´�
ξ Description: “Patients 18 years and older who screened positive for unhealthy alcohol
XVH�ZKR�UHFHLYHG�RU�UHIXVHG�D�EULHI�LQWHUYHQWLRQ�GXULQJ�WKH�KRVSLWDO�VWD\�´
o SUB-2 is an overall rate, which includes all patients to whom a brief intervention
was provided or offered and refused.
ξ Numerator: The number of patients who received or refused a brief intervention.
ξ Denominator: The number of hospitalized inpatients 18 years of age and older who
screen positive for unhealthy alcohol use disorder (alcohol abuse or alcohol
dependence).
ξ ABSTRACTOR COMMENTS:
o Patients (men and women) who score 6 or above on Audit C are required to
receive a brief intervention

SUB-2a ³$OFRKRO�8VH�%ULHI�,QWHUYHQWLRQ´
ξ Description: Patients who received the brief intervention during the hospital stay.
o SUB-2a is a subset and only includes those patients who received a brief
intervention
ξ Numerator: The number of patients who actually received a brief intervention.
ξ Denominator: The number of hospitalized inpatients 18 years of age and older who
screen positive for unhealthy alcohol use disorder (alcohol abuse or alcohol
dependence).

SUB-3 ³$OFRKRO�DQG�2WKHU�'UXJ�8VH�'LVRUGHU�7UHDWPHQW�3URYLGHG�RU�2IIHUHG�DW�'LVFKDUJH´�
AND the subset measure
ξ Description: Patients 18 years and older who are identified with alcohol or drug use
disorder and ZKR�³ZHUH�referred to or refused at discharge a prescription for FDA-
approved medications for alcohol or drug use disorder, OR who receive or refuse a
UHIHUUDO�IRU�DGGLFWLRQV�WUHDWPHQW�´
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20
o SUB-3 PXVW�EH�UHSRUWHG�DV�³DQ�RYHUDOO�UDWH�ZKLFK�LQFOXGHV�DOO�SDWLHQWV�WR�ZKRP�
alcohol or drug use disorder treatment was provided, or offered and refused, at
WKH�WLPH�RI�KRVSLWDO�GLVFKDUJH�´
ξ Numerator: The number of patients who received or refused at discharge a prescription
for medication for treatment of alcohol or drug use disorder OR received or refused a
referral for addictions treatment.
ξ Denominator: The number of hospitalized inpatients 18 years of age and older identified
with an alcohol or drug use disorder.

SUB-3a ³$OFRKRO�DQG�2WKHU�'UXJ�8VH�'LVRUGHU�7UHDWPHQW�DW�'LVFKDUJH´
ξ Description: A subset of SUB-��DQG�LGHQWLILHV�³3DWLHQWV�ZKR�DUH�LGHQWLILHG�ZLWK�DOFRKRO�RU�
drug disorder who receive a prescription for FDA-approved medications for alcohol or
drug use disorder OR D�UHIHUUDO�IRU�DGGLFWLRQV�WUHDWPHQW�´
o SUB-3a (subset) includes only those patients who received a prescription for
FDA-approved medications for alcohol or drug use disorder OR a referral for
addictions treatment
ξ Numerator The number of patients who received a prescription at discharge for
medication for treatment of alcohol or drug use disorder OR a referral for addictions
treatment.
ξ Denominator: The number of hospitalized inpatients 18 years of age and older identified
with an alcohol or drug use disorder.

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Instances occur when a patient’s alcohol or drug (AOD)
use is simply discussed during a visit and may not lead to
diagnosis or when a patient is ambiguous about a referral
to an addictions program. In those instances, it may be
appropriate to use one of the following AOD related codes –
Once you have diagnosed someone with alcohol or drug
abuse or dependence via an outpatient visit, intensive
outpatient visit, partial hospitalization, detoxification visit,
ED visit or inpatient discharge, the Healthcare Effectiveness
Data and Information Set (HEDIS®) has established measures
for initiating and engaging in treatment.
Initiation

If your patient is inpatient with a new* AOD abuse or
dependence diagnosis, then they are considered to have
initiated treatment.

If your patient is given a new* AOD abuse or dependence
diagnosis during an outpatient visit, they need to have
an additional outpatient visit, partial hospitalization or
admission with an AOD code within 14 days to be
compliant with the initiation measure.
* new means patient did not have an encounter with an AOD dependence
diagnosis code within the past 60 days.
Engagement
To be engaged in treatment, your patient would need to
have at least two additional inpatient admissions, outpatient
visits or partial hospitalizations with an AOD diagnosis.
This must have occurred within 30 days after the date of
initiation (the admission or first outpatient visit.)
Follow-up or Referral
If you have diagnosed your patient with AOD abuse or
dependence, it is important to either follow-up with that
patient yourself or refer them for AOD services. This
follow-up helps to assure that the patient fully initiates
and engages in treatment.
HEDIS® uses the following codes to identify patients for
inclusion in the Initiation and Engagement measure –
ICD-9
291.0 – 291.9 – Alcohol induced mental disorders
303.0 – 303.9 – Alcohol intoxication or dependence
304.0 – 304.9 – Drug dependence
305.0 – 305.9 – Alcohol or drug abuse
535.3 – Alcoholic gastritis
571.1 – Acute alcoholic hepatitis
ICD-10
F10.10 - F10.29 – Alcohol abuse / dependence
F11.10 - F11.29 – Opioid abuse / dependence
F12.10 - F12.29 – Cannabis abuse / dependence
F13.10 - F13.29 – Sedative abuse / dependence
F14.10 - F14.29 – Cocaine abuse / dependence
F15.10 - F15.29 – Other stimulant abuse / dependence
F16.10 - F16.29 – Hallucinogen abuse / dependence
F18.10 - F18.29 – Inhalant abuse / dependence
F19.10 - F19.29 – Other psychoactive substance
abuse / dependence
HEDIS® is a registered trademark of the National Committee for
Quality Assurance (NCQA).
Are You Making the Right Diagnosis?
Initiation and Treatment for Substance Use Disorders
Identifying patients who could benefit from substance use treatment and referring them to a program can be challenging.
Early identification and timely follow up, however, are critical to effectively address untreated substance use disorders.
A simple, straight forward approach in the physician’s office has been shown to be an effective intervention for many.
ICD-9
V79.1 – Special screening for alcoholism
V65.42 – Counseling on substance use and abuse
ICD-10
Z13.89 – Encounter for screening for other disorder
Z71.41 – Alcohol abuse counseling and surveillance
of alcoholic
Appendix G. HEDIS Measures Patients with a New AOD Diagnosis
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ALCOHOL ASSESSMENT TOOLS
For more information on assessment tools, please see Unity’s Alcohol CPG. All clinical practice
guidelines (CPGs) can be found by visiting unityhealth.com/clinicalguidelines.
To refer a Unity member for additional AOD services contact UW Health - Behavioral Health Care
Management at (800) 683-2300 or (608) 233-3575
– Female Patients:
How often do you drink four or
more drinks on a single occasion?
– Male Patients:
How often do you drink five or
more drinks on a single occasion?
UH01393 (1115) Unity Health Plans Insurance Corporation
For information exclusive to providers, please visit unityhealth.com/providers
A UW Health work group composed of primary care physicians, addiction and drug abuse specialists,
pharmacists, quality improvement and clinic management staff have developed a one-question screen for
excessive drinking. This simple tool can be used to help determine if a patient could benefit from a referral
for a comprehensive AOD evaluation.
Persons who report excessive alcohol use one or more times in the last month are considered a positive
screen and should receive brief assessment and intervention services.
UH01393(1115) v4.qxp_Layout 1 12/9/15 3:55 PM Page 2
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22
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2016CCKM@uwhealth.org