U.S.DEPARTMENTOFHEALTHANDHUMANSERVICES
A Note about Terms

In this document, we try to use terms in ways that focus on at-risk behaviors rather than 

individuals. Therefore, rather than referring to at-risk or problem drinkers, we refer to at-risk or 

problem drinking. Using language this way does not disparage our patients, and it also reminds us 

that behavior can change.

Throughout the document, we use hazardous, excessive, unhealthy, or at-risk drinking 

interchangeably. All these terms refer to the middle section of the triangle in Figure 1.

Acknowledgments

Kathryn Cates-Wessel, Physicians and Lawyers for National Drug Policy; Chris Dunn, PhD, University of 

Washington; Larry M. Gentilello, MD, University of Texas Southwestern Medical School, University of 

Texas School of Public Health; John C. Higgins-Biddle, PhD (retired), University of Connecticut Health 

Center; Daniel W. Hungerford, DrPH, Centers for Disease Control and Prevention; Carol R. Schermer, 

MD, MPH, Loyola University Stritch School of Medicine; Deborah Steinbach, The MayaTech Corporation; 

Tom Stegbauer, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services 

Administration. This document was designed and developed by The MayaTech Corporation.

Sponsors

AMERICAN COLLEGE OF SURGEONS 

Committee on Trauma

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control

National Institute on Alcohol Abuse and Alcoholism

Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment

DEPARTMENT OF TRANSPORTATION

National Highway Traffic Safety Administration


The Problem 

Addiction to alcohol is not the country’s only 

problem with alcohol. For every U.S. adult who is 

dependent on alcohol, more than 6 other adults 

who are not dependent are at risk of or have 

already experienced problems from their drinking.1

Many of these at-risk drinkers incur injuries that 

require trauma center services. 

The triangle on the right (Figure 1) shows that 

even if we were able to “cure” the 3.3% who are 

dependent,1 we would not have addressed the 

largest portion of the U.S. alcohol problem: the 

22.7% who are not dependent but have experienced 

problems or have significant risks related to their 

drinking.1 For the purposes of this document, 

these individuals engage in “at-risk drinking.” They 

drink at levels that place them at elevated risk for 

future alcohol-related problems, and some may 

already have suffered injuries (e.g., ended up in a 

trauma center). However, they are not dependent 

on alcohol. 

Not surprisingly, a high proportion of these atrisk drinkers find their way to trauma centers, 

where almost 50% of patients can have positive 

blood alcohol concentrations (BAC).2 Despite the 

prevalence of alcohol-related risk and problems, 

trauma centers do not currently provide screening 

and effective brief intervention as part of routine 

care. 

Because excessive drinking is a significant risk 

factor for injury, it is vital for trauma centers 

to have protocols in place to identify and help 

patients. Trauma centers are in an ideal position to 

take advantage of the teachable moment generated 

from an injury by implementing screening and 

brief intervention (SBI) for at-risk and dependent 

drinkers. 

Brief alcohol interventions conducted in trauma 

centers have been shown to reduce trauma 

recidivism by as much as 50%.2 Such interventions 

also reduce rates of arrest for driving under the 

influence3 and cut health care costs.4 For these 

reasons, routine care in trauma centers should 

include screening patients for alcohol misuse, 

providing brief interventions for patients who 

screen positive, and—when needed—referring 

patients to specialty assessment and treatment.

The Response 

In its publication Resources for Optimal Care of 

the Injured Patient: 2006, the American College of 

Surgeons Committee on Trauma (COT) includes 

the following essential criteria for trauma centers. 

“Trauma centers can use the teachable moment 

generated by the injury to implement an effective 

prevention strategy, for example, alcohol counseling 

for problem drinking. Alcohol is such a significant 

associated factor and contributor to injury that it 

is vital that trauma centers have a mechanism to 

identify patients who are problem drinkers. Such 

mechanisms are essential in Level I and II trauma 

centers. In addition, Level I centers must have the 

capability to provide an intervention for patients 

identified as problem drinkers. These have been 

shown to reduce trauma recidivism by 50%.”

Although this guide is intended to help Level I 

and II trauma centers implement SBI, the COT 

recommends that all trauma centers incorporate 

alcohol screening and brief intervention as part of 

routine trauma care.

3.3%

22.7%

74%

Figure 1: Pyramid of Alcohol Problems1

Drinking Type Intervention Type

Alcohol Dependence 

 in the Last Year

Brief Intervention 

 and Referral

No Alcohol Dependence, 

 but Binges or Heavy 

 Use in the Last Year

Brief Intervention

All Others No 

 Intervention

Note: The prevalence estimates in this figure are for noninstitutionalized U.S. population, not trauma patients. 


Alcohol Screening and Brief Intervention in Trauma Centers: 

A Simple Three-Step Process

Screen Patients

Screening for alcohol use identifies whether or not patients’ drinking places them and others at risk and 

hence warrants brief interventions. Some screening instruments can also provide information about the 

severity of patients’ problems and the likelihood of their being dependent on alcohol. This information is 

essential to delivering an appropriate intervention. If not obtained during screening, it can be acquired 

during the intervention itself.

Conduct Brief Intervention

In trauma centers, brief interventions capitalize on the fact that patients’ injuries help motivate behavior 

change. Most people undergoing behavior change do not require formal treatment. Brief interventions 

are a way to help this large group of patients reduce or eliminate their at-risk drinking. Brief 

interventions typically use three components.

a. Information or feedback about screening results, BAC upon admission, the link between drinking and 

injury, guidelines for low-risk alcohol consumption, methods for reducing or stopping drinking, etc. 

b. Understanding the patient’s view of drinking and enhancing motivation. This part of the 

intervention encourages patients to think about and express how drinking may have contributed to 

their injury, what they like and dislike about their current drinking pattern, and how they might want 

to change to reduce their risks. This process engages patients in the conversation so that they can 

come to their own decisions about drinking.

c. Clear and respectful professional advice about the need to reduce risk by cutting down or quitting 

drinking and to avoid high-risk alcohol-related situations. The patient/clinician interaction is also likely 

to require negotiating between what the clinician thinks is best and what the patient is willing and 

able to do. The optimal result is for patients to establish and articulate their own goals and a plan to 

achieve them.

Follow Up

Research indicates that patient outcomes improve when some follow up is provided. Trauma centers 

with sufficient resources can consider:

• Providing follow-up visits or telephone contact to reinforce the intervention.

• Recommending that patients consult their primary care providers or hospital specialists.

• Discussing options for additional services as needed, such as Alcoholics Anonymous or a local 

treatment organization.

Step 1

Step 2

Step 3


Identify Program Staff.

Trauma centers are required to identify at least one member of the trauma staff to receive training in how to 

administer SBI and to monitor and evaluate program activities. It is not necessary that the trained trauma staff 

member deliver all of the interventions, but he or she should provide SBI program oversight.

Define the Target Population of patients who will be screened. 

Recognizing that it might not be feasible to screen every patient, trauma centers are, nevertheless, expected to 

screen the majority of their patients—not just those who appear to be intoxicated. Because problem drinking 

is very common among trauma patients, many who are not intoxicated at admission will screen positive for 

problem drinking and therefore be at risk for future alcohol-related injury. 

Develop a Protocol for Screening.

Trauma centers must select one (or more) evidence–based screening instrument(s), identify who will 

administer the screening method, and decide when and where patients will be screened. See page 7 for 

recommended instruments and procedures.

Develop a Protocol to Provide Brief Interventions.

To meet this criterion, Level I trauma centers must, at a 

minimum, develop a plan to deliver brief interventions to screenpositive patients. The intervention can be provided by a trauma 

team member or other hospital staff (e.g., psychologist or social 

worker) who should be specially trained in providing a brief 

intervention to the full severity spectrum of at-risk drinkers. 

See page 9 for information about delivering brief interventions.

Develop a Record-Keeping Protocol.

The Verification Review Committee may ask for information on the screening instrument used, the percentage 

of patients screened, and who provides the interventions. Other measures useful for evaluating SBI include 

the percentage of patients who screen positive, the percentage of screen-positive patients who receive an 

intervention, and any records of follow up on patients, such as referral to treatment.

Establish a Mechanism to Ensure Patient Protection and Confidentiality.

The following article provides valuable guidance on issues and options relating to patient confidentiality: 

Gentilello L. Alcohol screening and intervention in trauma centers: confidentiality concerns and legal 

considerations. J Trauma. 2005:59:1-1.

Develop a Reimbursement Strategy. 

Some billing codes for SBI already exist, and new, more specific ones are being developed. Negotiation with 

payers unaccustomed to reimbursing for these codes may be necessary.

*Note: The Substance Abuse and Mental Health Services Administration (SAMHSA) will provide an online step-by-step guide at 

http://sbirt.samhsa.gov to assist trauma centers in their planning and implementation process.

Planning: Before Implementing a Program*

Drinking Guidelines

Healthy men up to age 65: • No more than 4 drinks in a day AND

• No more than 14 drinks in a week

Healthy adult women; healthy men over age 65: • No more than 3 drinks in a day AND

• No more than 7 drinks in a week

Lower limits or abstinence for patients who: • Take medications that interact with alcohol

• Have a health condition exacerbated by alcohol

Advise Patients NOT to Drink:

• When operating a vehicle or machinery

• When pregnant or considering pregnancy

• If a contraindicated medical condition is present

• After using certain medications, such as sedatives, 

analgesics, and selected antihypertensives

Source: National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism


Screening Methods

Because subjective judgment is an unreliable 

means of identifying at-risk drinking, the COT is 

requiring that an evidence-based screening process 

be administered to as many admitted trauma 

patients as feasible. Many factors should be taken 

into consideration in implementing a screening 

protocol, in addition to the choice of screening 

instruments that will be used.

First, each center should identify the target 

population it will screen. This group should 

include the largest possible portion of patients, 

but some groups may be excluded based on 

the likelihood of their not having a drinking 

problem (e.g., pre-adolescents) or the difficulty of 

conducting screening (e.g., those with significant 

traumatic brain injury). Most importantly, since 

alcohol misuse is pervasive among all adolescent 

and adult segments of society, no groups or 

individuals should be excluded based upon an 

assumption that they are not likely to be at risk.

Screening for alcohol use may serve more than 

one purpose within an SBI system. At a minimum, 

screening procedures must determine whether a 

brief intervention should be offered to a patient. 

Any of the screening procedures described 

below will provide this information. However, 

delivering an appropriate intervention also requires 

determining the severity of a patient’s drinking 

problem, including the likelihood of dependence. 

This information is critical to guiding the patient 

to an appropriate decision about how to reduce 

alcohol-related risks. 

Various alternatives are available to obtain the 

information necessary to know both (a) whether 

an intervention is appropriate and (b) how best 

to advise the patient, based on the severity of 

his or her drinking problem. Some screening 

instruments, such as the AUDIT and Consumption 

+ CAGE, provide sufficient information for 

deciding both questions before one begins the 

intervention. (See page 7.) The BAC or the singlequestion binge drinking screen, however, offer 

sufficient cause to begin an intervention but 

require that additional information about severity 

and dependence be obtained either by further 

screening or by asking questions during the 

intervention. 

A screening protocol should also take into account 

the possibility of patients underreporting their 

alcohol use in response to questions. Even though 

research shows that patients in most medical 

settings answer questions with sufficient honesty to 

provide reliability, some patients in trauma settings 

may have overriding reasons to underreport their 

drinking. Although a patient who underreports 

drinking may still screen positive, careful probing 

and confirmation of drinking patterns is advised 

during the intervention. A BAC can be used to 

verify patient-reported information about current 

intoxication.

Thus, the selection of an instrument and 

determination of screening procedures must be 

decided in light of the entire SBI protocol being 

established. It may make sense to use a screening 

instrument that provides all the information 

needed before the intervention begins. On the 

other hand, a center may decide to use only a 

BAC or very short screening questionnaire to 

identify patients in need of an intervention, and 

gather additional information about severity and 

dependence during the intervention itself. Both 

systems can work with equal effectiveness.

Introducing the screening process as part of the 

trauma center’s normal routine helps the patient 

feel as though he or she has not been singled out 

or already labeled as a person with a drinking 

problem. Some introduction to set the patient 

at ease is advisable, such as “Hi, I work with the 

trauma team; we like to ask all patients a few 

questions about their alcohol use. Would now be a 

good time?”


1. Alcohol Use Disorders Identification Test (AUDIT)

Description: This 10-item screening instrument 

was developed through international testing by 

the World Health Organization. The AUDIT asks 

questions about alcohol consumption during the 

past year, symptoms of alcohol dependence, and 

alcohol-related problems. It identifies 4 different 

groups of people—those unlikely to be at risk, 

those at risk because they drink excessively, those 

who have already experienced problems related 

to their drinking, and those who are likely to have 

alcohol dependence syndrome. (See page 12 for the 

full instrument.)

Use: The AUDIT can be administered in 2-3 

minutes, through an interview, by the patient on 

paper, or by computer. 

Cutoff Scores: Patients meeting or exceeding the 

following cut off scores should be offered a brief 

intervention. 

Adult men under age 66: 8 or above

All adult women; men over age 65: 7 or above

Adolescents under age 18: 4 or above

The AUDIT can be used to evaluate the severity 

of a patient’s drinking problem. Therefore, it can 

be helpful in deciding what advice to give patients 

during an intervention.

An AUDIT score of 16–19 suggests severe 

alcohol-related problems. The patient should 

be encouraged to seek additional help.

An AUDIT score of 20 or more suggests 

alcohol dependence syndrome, which may 

require specialized treatment.

Advantages: AUDIT is sensitive to a broad 

spectrum of drinking problems, from early 

excessive use to severe dependence. It has been 

extensively validated, including in trauma centers, 

and performs well with a wide variety of ethnic and 

cultural groups. It is available in Spanish and many 

other languages. It provides information about the 

three major domains of alcohol problems—alcohol 

consumption, alcohol-related problems, and 

alcohol dependence symptoms, all of which are 

valuable in conducting an appropriate intervention.

Description of Screening Instruments

2. Consumption + CAGE Questions

Description: This screening method combines 

3 alcohol consumption questions that identify a 

patient’s current drinking pattern with the CAGE 

questionnaire. The CAGE utilizes 4 questions to 

identify patients with alcohol dependence syndrome; 

1) Have you ever felt you should Cut down on your 

drinking? 2) Have people Annoyed you by criticizing 

your drinking? 3) Have you ever felt bad or Guilty 

about your drinking? 4) Have you ever had an Eye 

opener first thing in the morning to steady nerves or 

get rid of a hangover? Together, the consumption 

questions and the CAGE identify patients whose 

drinking puts them at risk of having alcohol 

problems in addition to identifying the likelihood of 

dependence. 

The consumption questions are: 

1. On average, how many days per week do you have 

a drink containing alcohol? 

2. On a typical day when you drink alcohol, how 

many drinks do you have? 

3. How many times in the past year have you had x 

(x=5 for men; x=4 for women) or more drinks in 

a day?

Use: This method can be administered in about 

2 minutes by an interviewer or completed by the 

patient on paper or by computer. In interview or 

computer format, questioning can stop if the first 

question is 0 or none and if the response to question 

3 is 0. Preface the screening by explaining that the 

consumption questions relate to drinking in the 

prior month and what constitutes a drink, i.e., one 

beer, one glass of wine (5 oz.), or one standard mixed 

drink (one shot or 1.5 oz. of 80 proof spirits). Note 

that the four CAGE questions refer to the patient’s 

lifetime drinking experience.

Cutoff Scores: The patient is considered positive if: 

• The product of responses to questions 1 and 

2 produces a total number of drinks per week 

exceeding the recommended weekly guidelines (7 

for women and anybody older than 65; 14 for men 

under age 66); OR 

• The response to question 3 is more than 0; OR 

• The patient answers “yes” to 2 or more of the 4 

CAGE questions. 


Advantages: Many medical personnel have been 

taught the CAGE questions and may therefore be 

more comfortable using them. This method provides 

information on both consumption and possible 

dependence making it useful in delivering an 

appropriate intervention.

3. CRAFFT

Description: This instrument was specifically 

designed to screen for alcohol and drug problems 

in adolescents. Rather than asking direct questions 

about quantities and frequencies of alcohol and drug 

consumption, it asks 6 questions about behaviors 

that are reliable indicators of consumption and risk. 

Use: No prior explanation to the patient is required.

Cutoff Scores: Two or more positive answers 

indicate a possible problem.

Advantages: The instrument was designed 

especially for adolescent screening. It includes drug 

as well as alcohol use.

4. Blood Alcohol Concentration (BAC)

Description: Alcohol concentration is determined 

by the weight of ethanol (ethyl alcohol) in a volume 

of blood. The typical measure is grams of ethanol 

in 100 milliliters of blood and is reported as 0.10 

g/dl or 100 mg/dl. Thus, it detects the presence of 

intoxication rather than regular weekly or occasional 

excessive use. However, intoxication accompanied 

by trauma is sufficient reason to conclude that 

drinking behavior was related to the risk that 

produced injury.

Use: If the blood sample was not drawn near the 

time of the injury, BAC may underestimate the 

patient’s drinking. In order to calculate the BAC at 

the time of injury, add 15 mg/dl for each hour that 

has elapsed between the time of the injury and when 

the blood sample was drawn. 

Cutoff Scores: The BAC threshold for impaired 

driving is 80 mg/dl (0.08 g/dl) in all 50 U.S. states. 

This threshold was set because research shows that 

driving ability is impaired at this level for everyone. 

Because most people’s ability to drive is impaired 

at lower BAC levels, many other countries have set 

the threshold at 0.05 g/dl for adults and lower for 

adolescent drivers, generally between .00 g/dl and 

.02 g/dl. 

Advantages: BAC is a quick, simple, and objective 

screening method. If the majority of patients are 

routinely tested, it requires no new personnel 

or functions other than acting upon the results. 

It provides sufficient initial information if the 

subsequent counseling session identifies typical 

consumption patterns, other related problems, 

and signs of dependence, which are important 

in guiding the intervention in an appropriate 

direction.

5. Binge Drinking Question

Description: A single screening question about 

whether a patient has recently consumed more 

than 5 drinks in one day (more than 4 drinks 

for females) has been found to be effective in 

identifying at-risk drinking among patients who 

have injuries. 

Use: The question can be included on an intake 

questionnaire. If it is asked in the context of 

collecting other patient information, efforts must 

be made to assure it is asked of the majority of 

patients.

Cutoff Scores: Patients who report having 

exceeded the requisite number of drinks within the 

past 3 months are considered positive. 

Advantages: This is a simple, quick, and 

easy method of screening injured patients to 

identify those likely to benefit from brief alcohol 

counseling. 


Brief Interventions

Three Components of Brief Interventions 

• Giving information/feedback can include telling patients something specific to their 

unique situation, such as their scores on a screening questionnaire or their BAC results 

from a laboratory test administered upon admission. Giving information might include 

telling patients that drinking soon after surgery can lead to further injuries. It might also 

include educating patients about recommended drinking limits or how abstaining or 

cutting down can greatly reduce the risk of future injuries. 

• Understanding patients’ views of drinking and enhancing motivation means 

asking about and understanding their perceptions about drinking. This might include 

asking them if they think that drinking played a role in their injuries. It might entail 

asking patients their views of the good and less than good things about drinking. How 

important do patients think it is to change? How confident are they that they could 

change if they decided to? Such questions engage patients in a conversation so that 

they can think themselves to a decision about their drinking. This conversation should 

be conducted in a collaborative, non-confrontational manner. Understanding patients’ 

views about drinking not only demonstrates respect for patients, it is likely to elicit 

information that will improve rapport and can be used during the intervention. 

• Giving advice and negotiating may include advising patients to cut down or quit, to 

avoid driving after drinking, or perhaps even to seek professional help or self help such 

as Alcoholics Anonymous. This often involves a compromise between what the clinician 

thinks is safest and what the patient is willing to do. Topics typically covered in this 

component include goal setting (quitting drinking versus cutting down) and forming a 

plan (telling a girlfriend about one’s goal, avoiding certain people or places, etc.). While 

providing advice, it is important to convey respectful concern for the patient and not to 

be sarcastic, judgmental, or authoritarian. 

The overall aim of a brief intervention is to help patients decide to lower their risk for alcohol-related problems. 

Clinicians can use the following types of components to achieve this end.

Brief Intervention FAQs

Are brief interventions only used for dealing with alcohol issues?

In fact, brief interventions are widely used by physicians and other medical staff to address an array of patient 

behaviors including dietary habits, weight loss, smoking, and taking medications as prescribed. Research 

evidence clearly shows that brief interventions for at-risk drinking result in health, social, and economic 

benefits for the individual and society. 
10

Are all types of alcohol interventions the same?

Traditionally, hospital psychiatry, social work, and substance abuse consultation teams have focused their work on 

treating patients with the most severe alcohol problems, primarily those with dependence. However, research has 

shown (see Figure 1) that the majority of patients with alcohol problems, in particular those in trauma settings, do 

not meet the criteria for dependence. Therefore, brief interventions were developed to address this larger group 

of patients with mild-to-moderate alcohol problems. This new approach requires staff who, in the past, worked 

primarily with alcohol dependent patients to acquire additional skills that are appropriate for addressing the needs 

of patients with less severe problems. 

How long should a brief intervention last?

A brief intervention can range from a simple advice session of 5 minutes to 1-hour counseling session. Both very 

short and longer interventions have been shown to be effective. The length of the intervention should depend on 

the type of advice or counseling that would most benefit the patient and the willingness of the patient to receive it. 

What types of patients can benefit most from brief interventions?

Screening and brief intervention was designed to help patients who are not severely addicted to alcohol and who 

still have enough control over their drinking that they can cut down or quit with little or no professional help. 

Many patients in trauma centers are likely to fit these criteria, so trauma centers are ideally positioned to deliver 

a brief intervention during a teachable moment that in itself motivates many patients to change. The respectful 

concern of the clinician can result in many patients avoiding subsequent injuries or turning away from a path 

toward alcohol dependence. Like many other clinical functions, brief intervention does not work for everyone all 

of the time. However, if provided for the majority of at-risk drinkers, it will over time result in less drinking and a 

large reduction in future injuries. 

Does this mean that trauma centers should withhold brief intervention from more severely afflicted patients?

No. Although patients with the most severe drinking problems (e.g., extreme withdrawal symptom, multiple 

medical sequelae, and organic brain damage) might benefit from help beyond a brief intervention, a brief 

intervention is much better than nothing. Often, a brief intervention can motivate patients to seek help in 

professional treatment or a self-help program such as Alcoholics Anonymous. Providing a brief intervention to 

these patients will result in more of these patients seeking help sooner. 

Who can perform the brief intervention?

Brief intervention does not have to be administered by a state-certified substance abuse counselor or by other 

clinicians with advanced training in substance abuse treatment. After relatively little training, brief intervention 

can be performed by anyone capable of showing respect and concern for injured patients. In addition to mental 

health or substance abuse counselors, the COT believes that there are multiple people in each trauma center 

who can meet these criteria, including surgeons or other MDs, psychologists, physician assistants, nurses, social 

workers, and spiritual care workers.

How does one learn to provide a brief intervention?

Although “live training” may be superior to self teaching and online computer learning, the COT believes that 

not all trauma centers can afford a live trainer. Live training in SBI can vary from a 1-hour visit by a trauma nurse 

trainer to a four-day workshop in more advanced techniques of motivational counseling. Trauma centers are 

encouraged to start by using any of the online training Web sites listed on page 14.
11

The patient has positive screening results. However, because the AUDIT indicates that the patient has an early, 

and relatively mild, drinking problem, only simple advice is needed. This intervention takes about 3 minutes.

Transition statement 

to move from 

screening to brief 

intervention

CLINICIAN: Thank you for answering those questions. Would you be interested to 

find out how your score on this questionnaire compares with other people? 

PATIENT: Sure, I guess.

Giving information/

feedback 

CLINICIAN: Okay. Well those 10 questions have been given to thousands of 

people around the world so that people can find out whether it would be good for 

them to change their drinking. Scores can range from 0–40. Scores between 0–6 

(women)/0–7(men) are considered low-risk drinking; scores between 8–15 are 

considered hazardous drinking, and scores above 15 likely indicate more serious 

alcohol problems. Your score was 9, which puts your drinking in the hazardous 

range.

PATIENT: Oh wow.

Understanding 

patients’ views 

of drinking and 

enhancing motivation

CLINICIAN: Surprised?

PATIENT: Yeah. I figured I’d be, you know, in the lowest range.

CLINICIAN: So you thought your drinking was less than average...

PATIENT: Yeah, I mean my friends drink more than me. I’m not an alcoholic or 

anything like that. 

CLINICIAN: Well, let’s not worry so much about labels here. I’m more concerned 

about whether your drinking is going to hurt you in the future or not.

PATIENT: Yeah. 

CLINICIAN: Many of our patients are surprised to learn what their scores are, and 

it’s just an opportunity to think about making a change. If you were to do that, your 

chances of avoiding another injury in the future would be much better.

PATIENT: I don’t know about quitting, that seems like way overkill for me. But 

maybe I could cut down.

Giving advice and 

negotiating 

CLINICIAN: Many patients can successfully cut down so they reduce their risk of 

injury and other problems. Men who are successful in cutting down are able to drink 

no more than 4 standard drinks per occasion and no more than 14 drinks per week. 

What do you think you’ll do?

PATIENT: Well, I guess I could give it a try. It’s not like it’s a big deal to me or 

anything...

CLINICIAN: That’s really great. You sound determined. So your limit would be no 

more than 4 drinks per occasion (beers, 5 oz. of wine or a mixed drink with 1.5 oz of 

spirits), and no more than 14 drinks per week. It’s a good opportunity for you to test 

your control over alcohol. Just remember that this guideline means you can’t have all 

of your weekly drinks in one day! (both laugh) And most important of all, no drinks 

at all if you’re driving.

PATIENT: Yeah, well I think I can stay under those limits pretty easily. And also, I 

never drink and drive anyway. 

CLINICIAN: Really? That’s great to hear. How do you avoid that? 

PATIENT: If I take my car out, I just don’t drink anything, period, end of story. And if 

I know I’m going to drink, I use a designated driver.

Closing on good terms CLINICIAN: Good for you, and thanks for talking with me.

Sample Brief Intervention
12

Questions 0 1 2 3 4

1. How often do you have a drink containing 

alcohol? Never Monthly 

or less

Two to 

four times 

a month

Two to 

three times 

a week

Four or 

more times 

a week

2. How many drinks containing alcohol do you 

have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more

3. How often do you have five or more drinks on 

one occasion? Never Less than 

monthly Monthly Weekly Daily or almost daily

4. How often during the last 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

5. How often during the last year have you failed 

to do what was normally expected from you 

because of drinking?

Never Less than 

monthly Monthly Weekly Daily or almost daily

6. How often during the last 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

7. How often during the last year have you had a 

feeling of guilt or remorse after drinking? Never Less than 

monthly Monthly Weekly Daily or almost daily

8. How often during the last 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

9. Have you or someone else been injured as a 

result of your drinking? No

Yes, but 

not in the 

last year

Yes, during 

the last year

10. Has 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 the 

last year

Yes, during 

the last year

Total

AUDIT: Self-Report Version 

Instructions to patients: Because alcohol use can affect your health and can interfere with certain medications 

and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain 

confidential so please be honest. Place an x in one box that describes your answer to each. Please think about your 

drinking in the past year and remember that a drink means one beer, one small glass of wine (5 oz.), or one mixed 

drink containing one shot (1.5 oz.) of spirits.

Available for clinical use without permission from the World Health Organization. The international version has been slightly 

altered here to adjust it partially to the 14 g. standard drink in the U.S.A. by changing “six” to “five” in Question 3. A manual 

on the use of the AUDIT and another on brief interventions are available at http://www.who.int/substance_abuse/publications/

alcohol/en/index.html. In interview or computer format, questioning can stop if the first question receives a negative answer or 

if the score of questions 2 and 3 are zero. Note that women who drink somewhat above recommended guidelines of 7 drinks per 

week may score zero on question 2 and not receive a positive screening result.

Appendix A: Recommended Screening Instruments 
13

Consumption + CAGE

Consumption

1. On average, how many days per week do you have a drink containing alcohol?

2. On a typical day when you drink alcohol, how many drinks do you have? 

3. How many times in the past year have you had x (x=5 for men; x=4 for women) or more drinks in a day?

CAGE

4. Have you ever felt you should Cut down on your drinking?

5. Have people Annoyed you by criticizing your drinking?

6. Have you ever felt bad or Guilty about your drinking?

7. Have you had an Eye opener first thing in the morning to steady nerves or get rid of a hangover?

Source: Ewing JA. Detecting alcoholism, the CAGE questionnaire. Journal of the American Medical Association. 252(14): 1905-1907, 1984.

CRAFFT

1. Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using 

alcohol or drugs?

2. Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?

3. Do you ever use alcohol or drugs while you are by yourself Alone?

4. Do you ever Forget things you did while using alcohol or drugs?

5. Do your Family or Friends ever tell you that you should cut down on your drinking or drug use?

6. Have you ever gotten into Trouble while you were using alcohol or drugs?

Source: Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent 

clinic patients. Archives of Pediatrics & Adolescent 156(6) 607-614, 2002.

Binge Drinking Question

1. When was the last time you had more than x (x=5 for men; x=4 for women) drinks in 1 day?

Sources: Canagasaby A, Vinson DC. Screening for hazardous or harmful drinking using one or two quantity-frequency questions. Alcohol 

Alcohol. 2005;40(3):208-213.

Williams RH, Vinson DC. Validation of a single question screen for problem drinking. Journal of Family Practice. 50(4):307-312, 2001.
14

Appendix B: Additional Resources 

SAMHSA’s Screening, Brief Intervention, Referral, and Treatment Web Site

A single, comprehensive repository of SBIRT information, including training manuals, online resources, links to 

organizations and publications, and a list of references. http://sbirt.samhsa.gov.

Self Training

Helping Patients Who Drink Too Much. A Clinician’s Guide 

U.S. Department of Health & Human Services, National Institutes of Health, National Institute on Alcohol Abuse and 

Alcoholism. NIH Publication No. 05-3769. 2005. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/

clinicians_guide.htm

AlcoholCME

This is an NIAAA-funded online continuing education course for intervening with alcohol problems (fee applies for CEU; 

registration and learning are free). It includes an introduction to the FRAMES model of brief intervention. http://www1.

alcoholcme.com/PageReq?id=1:8029

Alcohol Clinical Training (ACT)

This project disseminates research-based information and provides training to increase screening and brief intervention 

for alcohol problems. http://www.bu.edu/act/index.html

Lifestyle Change (Rapid Reference Series)

By Chris Dunn and Stephen Rollnick. Published by C.V. Mosby, London, England, 2003. 88 p. Price $27.95 (pocket sized, 

softcover).

Health Behavior Change: A Guide for Practitioners

By Stephen Rollnick, Pip Mason, and Christopher Butler. Published by Churchill Livingstone, Robert Stevenson House, 

1–3 Baxter’s Place, Edinburgh, Scotland EH1 3AF, 1999. 240 p. Price $29.95 (paperback).

Practice Guidelines and General Information

The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care (Second Edition)

By Thomas F. Babor, John C. Higgins-Biddle, John B. Saunders and Maristela G. Monteiro. Published by the Department of 

Mental Health and Substance Dependence, World Health Organization, 2001. http://whqlibdoc.who.int/hq/2001/WHO_

MSD_MSB_01.6a.pdf

Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care

By Thomas F. Babor and John C. Higgins-Biddle. Published by the Department of Mental Health and Substance 

Dependence, World Health Organization, 2001. http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6b.pdf

Alcohol and Other Drug Screening of Hospitalized Trauma Patients

Treatment Improvement Protocol (TIP) Series 16. U.S. Department of Health and Human Services, Substance Abuse and 

Mental Health Services Administration, Center for Substance Abuse Treatment, Rockville, MD 20857. DHHS Publication 

No. (SMA) 95-3041, 1995. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.36481 

Brief Interventions and Brief Therapies for Substance Abuse Treatment

Treatment Improvement Protocol (TIP) Series 34. U.S. Department of Health and Human Services, Substance Abuse and 

Mental Health Services Administration, Center for Substance Abuse Treatment. Rockville, MD 20857. DHHS Publication 

No. (SMA) 99-3353, 1999. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.59192

Guide to Substance Abuse Services for Primary Care Physicians

Treatment Improvement Protocol (TIP) Series 24. U.S. Department of Health and Human Services, Substance Abuse and 

Mental Health Services Administration, Center for Substance Abuse Treatment. DHHS Publication No. (SMA) 97-3139, 

1997. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.45293

Motivational Interviewing

The Mid-Atlantic Addiction Technology Transfer Center maintains a Web site of resources on motivational training.

http://www.motivationalinterviewing.com
15

References

1

Substance Abuse and Mental Health Services Administration. Results from the 2005 National Survey on Drug 

Use and Health: National Findings. Rockville (MD): Office of Applied Studies; 2006. NSDUH Series H-30, 

DHHS Publication No. SMA 06-4194.

2

Gentilello LM, Rivara FP et al. Alcohol interventions in a trauma center as a means of reducing the risk of 

injury recurrence. Ann Surg. 1999;230:473-80.

3

Schermer CR, Moyers TB et al. Trauma center brief interventions for alcohol disorders decrease subsequent 

driving under the influence arrests. J Trauma. 2006;60:29-34.

4

Gentilello LM, Ebel BE et al. Alcohol interventions for trauma patients treated in emergency departments and 

hospitals: a cost-benefit analysis. Ann Surg. 2005;241(4):541-55.
DHHS Publication No. (SMA) 07-4266

Substance Abuse and Mental Health Services Administration

Printed 2007