Laboratory Studies

Biomarkers

Alcohol biomarkers are physiological indicators of alcohol exposure or ingestion and may reflect the presence of an alcohol use disorder. These biomarkers are not meant to be a substitute for a comprehensive history and physical examination by an appropriate health professional. Instead, alcohol biomarkers should be a complement to self-reported measures of drinking.^[4]

In a population of psychiatric patients, research evidence has shown the usefulness of biological measures in the detection of alcohol use disorders when compared with patient self-report. A 2007 study of 486 consecutively admitted psychiatric patients showed a low correlation between self-reported consumption of alcohol and illicit drugs and biological measures; 52% of the patients underreported their consumption of illicit drugs when compared with urine toxicology screening results; 56% of patients underreported alcohol use as evaluated by carbohydrate-deficient transferrin (CDT), and 37% of patients underreported alcohol use as evaluated by CDT + gamma glutamyltransferase (GGT).^[39]Replication of such research in a primary care population is needed to show that biological measures aid the primary care clinician in detecting alcohol use disorders.

Alcohol biomarkers are generally divided into indirect and direct biomarkers.^[4]

Indirect alcohol biomarkers suggest heavy alcohol use by detecting the toxic effects that alcohol may have had on organ systems or body chemistry.^[4]

Indirect alcohol biomarkers include aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyltransferase (GGT), mean corpuscular volume (MCV), and carbohydrate-deficient transferrin (CDT).^[4]
GGT, AST, and MCV are the most frequently used indirect biomarkers.^[5]As a screen for alcohol dependence, the sensitivity/specificity of CDT is generally higher than AST, ALT, GGT, or MCV.^{[4, 40, 6]}(See Table 2 below.) CDT is less sensitive/specific in women than men.^[41]
CDT is a collection of various isoforms of the iron transport protein transferrin.^[5]Alcohol consumption above 50-80 g/d for 2-3 weeks appears to increase serum concentrations of CDT.^{[6, 40]}CDT tends to distinguish chronic heavy drinkers from light social drinkers.^[5]A number of different ways are available to measure CDT; some may be better than others, depending on factors such as the type of alcohol consumption and gender.^[42]
The combination of GGT and CDT compared with GGT or CDT alone shows a higher diagnostic sensitivity, a higher diagnostic specificity, and a stronger correlation with the actual amounts of alcohol consumption (see Table 2 below).^{[40, 6]}Combination GGT/CDT values appear to increase after the daily alcohol consumption exceeds a threshold of 40 g.^[6]This approach is cost-effective, easy to manage in hospital laboratories, and should be suitable for routine clinical care.^[6]
Other indirect alcohol biomarkers of emerging interest include total serum sialic acid (TSA), 5-hydroxytryptophol (5-HTOL), N-acetyl-beta-hexosaminidase (Beta-Hex), plasma sialic acid index of apolipoprotein J (SIJ), and salsolinol.^[7]

Direct alcohol biomarkers are analytes of alcohol metabolism.^[4]

Direct alcohol biomarkers include alcohol itself and ethyl glucuronide (EtG).^[4]
A blood alcohol level might be helpful in the office if the patient appears intoxicated but is denying alcohol abuse. A blood alcohol level in excess of 300 mg/dL, a blood alcohol level of greater than 150 mg/dL without gross evidence of intoxication, or a blood alcohol level of greater than 100 mg/dL upon routine examination indicates alcoholism with a high degree of reliability. The short half-life of alcohol limits its use widely as a biomarker.^[6]As the blood alcohol level detects alcohol intake in the previous few hours, it is not necessarily a good indicator of chronic excessive drinking.^[5]
EtG is a minor, nonoxidative, water-soluble, stable, and direct metabolite of alcohol that is formed by the conjugation of ethanol with activated glucoronic acid.^{[40, 6, 5]}Shortly after alcohol intake, even in small amounts, EtG becomes positive.^[5]After complete cessation of alcohol intake, EtG can be detected in urine for up to 5 days after heavy binge drinking^{[7, 6]}, making EtG an important biomarker of recent alcohol consumption.^[5]A 2006 report by the Substance Abuse and Mental Health Services Administration states that the use of EtG should be considered as a potential valuable clinical tool, but the use of EtG in forensic settings is premature.^[4]
Other direct alcohol biomarkers of emerging interest include acetaldehyde, fatty acid ethyl esters (FAEE), Ethyl Sulfate (EtS), and Phosphatidylethanol (PEth).^{[4, 7]}

Table 2. Sensitivity and Specificity of Alcohol Biomarkers* (Open Table in a new window)

Biomarker	Sensitivity (%)	Specificity (%)
AST	15-69	47-68
ALT	18-58	50-57
GGT	34-85	11-95
MCV	34-89	26-95
CDT	39-94	82-100
CDT + GGT	90 †	98
Alcohol	0-100	0-100
EtG	76-91	77-92
*Values vary considerably according to gender, age, drinking pattern, prevalence of alcohol abuse/dependence, and prevalence of comorbidity, among other factors.^{[40, 6, 41, 43, 44]} † The sensitivity comes from one study in Finland, which uses a special formula. This study needs to be replicated.^[45]

Other Tests

The possibility of polysubstance abuse/dependence justifies performing a blood/urine toxicology screen for other substances of abuse.

Treatment & Management

Anderson P. WHO Reports 3 Million Alcohol-Related Deaths in 2016. Medscape Medical News. Available at https://www.medscape.com/viewarticle/902614. September 27, 2018; Accessed: October 2, 2018.
Poznyak V, Rekve D. Global status report on alcohol and health 2018. World Health Organization. September 21, 2018. Available at http://www.who.int/substance_abuse/publications/global_alcohol_report/gsr_2018/en/.
Sacks JJ, Gonzales KR, Bouchery EE, Tomedi LE, Brewer RD. 2010 National and State Costs of Excessive Alcohol Consumption. Am J Prev Med. 2015 Nov. 49 (5):e73-9. [QxMD MEDLINE Link].
Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment. The Role of Biomarkers in the Treatment of Alcohol Use Disorders. US Department of Health and Human Services. September 2006. Available at http://kap.samhsa.gov/products/manuals/advisory/pdfs/0609_biomarkers.pdf.
Das SK, Dhanya L, Vasudevan DM. Biomarkers of alcoholism: an updated review. Scand J Clin Lab Invest. 2008. 68(2):81-92. [QxMD MEDLINE Link]. [Full Text].
Niemelä O. Biomarkers in alcoholism. Clin Chim Acta. 2007 Feb. 377(1-2):39-49. [QxMD MEDLINE Link].
Peterson K. Biomarkers for alcohol use and abuse. Alcohol Research & Health. 2004/2005. 28:
Substance Abuse and Mental Health Services Administration (SAMHSA). 2015 National Survey on Drug Use and Health (NSDUH). SAMHSA. Available at https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.htm#tab2-46b. 2015; Accessed: September 12, 2017.
Vaillant GE. A long-term follow-up of male alcohol abuse. Arch Gen Psychiatry. 1996 Mar. 53(3):243-9. [QxMD MEDLINE Link].
Lopez-Quintero C, Cobos JP, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011 May 1. 115(1-2):120-30. [QxMD MEDLINE Link]. [Full Text].
CDC Press Release. Binge drinking is bigger problem than previously thought. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/media/releases/2012/p0110_binge_drinking.html. Accessed: January 10, 2012.
Nutt DJ, King LA, Phillips LD. Drug harms in the UK: a multicriteria decision analysis. Lancet. 2010 Nov 6. 376(9752):1558-65. [QxMD MEDLINE Link].
Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to alcohol consumption: a prospective study among male British doctors. Int J Epidemiol. 2005 Feb. 34(1):199-204. [QxMD MEDLINE Link].
Knoops KT, de Groot LC, Kromhout D, Perrin AE, Moreiras-Varela O, Menotti A. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA. 2004 Sep 22. 292(12):1433-9. [QxMD MEDLINE Link].
Thun MJ, Peto R, Lopez AD, et al. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. N Engl J Med. 1997 Dec 11. 337(24):1705-14. [QxMD MEDLINE Link].
Pletcher MJ, Varosy P, Kiefe CI, Lewis CE, Sidney S, Hulley SB. Alcohol consumption, binge drinking, and early coronary calcification: findings from the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J Epidemiol. 2005 Mar 1. 161(5):423-33. [QxMD MEDLINE Link].
Ruidavets JB, Ducimetiere P, Evans A, Montaye M, Haas B, Bingham A. Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME). BMJ. 2010. 341:c6077. [QxMD MEDLINE Link].
Sood B, Delaney-Black V, Covington C, et al. Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. dose-response effect. Pediatrics. 2001 Aug. 108(2):E34. [QxMD MEDLINE Link].
Baer JS, Sampson PD, Barr HM, et al. A 21-year longitudinal analysis of the effects of prenatal alcohol exposure on young adult drinking. Arch Gen Psychiatry. 2003 Apr. 60(4):377-85. [QxMD MEDLINE Link].
Ault, A. Proven Screening Tool for Alcohol Abuse Underutilized. Medscape Medical News. Available at http://www.medscape.com/viewarticle/861116. March 29, 2016; Accessed: April 7, 2016.
Grant BF, Goldstein RB, Saha TD, Chou SP, Jung J, Zhang H, et al. Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015 Aug. 72 (8):757-66. [QxMD MEDLINE Link].
Arria AM, Caldeira KM, Kasperski SJ, Vincent KB, Griffiths RR, O'Grady KE. Energy Drink Consumption and Increased Risk for Alcohol Dependence. Alcohol Clin Exp Res. 2010 Nov 12. [QxMD MEDLINE Link].
Brauser D. New Guidelines for Alcohol Misuse in Adults Released. Medscape Medical News. Available at http://at http://www.medscape.com/viewarticle/804212.
Moyer VA; U.S. Preventive Services Task Force. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013 May 14. doi:10.7326/0003-4819-159-3-201308060-00652. [Epub ahead of print].
Enoch MA, Goldman D. Problem drinking and alcoholism: diagnosis and treatment. Am Fam Physician. 2002 Feb 1. 65(3):441-8. [QxMD MEDLINE Link].
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999 Nov 10. 282(18):1737-44. [QxMD MEDLINE Link].
Boutin-Foster C, Ferrando SJ, Charlson ME. The Cornell Psychiatric Screen: a brief psychiatric scale for hospitalized medical patients. Psychosomatics. 2003 Sep-Oct. 44(5):382-7. [QxMD MEDLINE Link].
Nery FG, Stanley JA, Chen HH, Hatch JP, Nicoletti MA, Serap Monkul E, et al. Bipolar disorder comorbid with alcoholism: A (1)H magnetic resonance spectroscopy study. J Psychiatr Res. 2009 Oct 7. [QxMD MEDLINE Link]. [Full Text].
Hicks BM, Krueger RF, Iacono WG, McGue M, Patrick CJ. Family transmission and heritability of externalizing disorders: a twin-family study. Arch Gen Psychiatry. 2004 Sep. 61(9):922-8. [QxMD MEDLINE Link].
Schuckit MA, Smith TL. An 8-year follow-up of 450 sons of alcoholic and control subjects. Arch Gen Psychiatry. 1996 Mar. 53(3):202-10. [QxMD MEDLINE Link].
Chengappa KN, Levine J, Gershon S, Kupfer DJ. Lifetime prevalence of substance or alcohol abuse and dependence among subjects with bipolar I and II disorders in a voluntary registry. Bipolar Disord. 2000 Sep. 2(3 Pt 1):191-5. [QxMD MEDLINE Link].
Jacobsen LK, Southwick SM, Kosten TR. Substance use disorders in patients with posttraumatic stress disorder: a review of the literature. Am J Psychiatry. 2001 Aug. 158(8):1184-90. [QxMD MEDLINE Link].
Vlahov D, Galea S, Ahern J, Resnick H, Boscarino JA, Gold J. Consumption of cigarettes, alcohol, and marijuana among New York City residents six months after the September 11 terrorist attacks. Am J Drug Alcohol Abuse. 2004 May. 30(2):385-407. [QxMD MEDLINE Link].
Marshall RD, Galea S. Science for the community: assessing mental health after 9/11. J Clin Psychiatry. 2004. 65 Suppl 1:37-43. [QxMD MEDLINE Link].
Shipherd JC, Stafford J, Tanner LR. Predicting alcohol and drug abuse in Persian Gulf War veterans: what role do PTSD symptoms play?. Addict Behav. 2005 Mar. 30(3):595-9. [QxMD MEDLINE Link].
Green B. Post-traumatic stress disorder: symptom profiles in men and women. Curr Med Res Opin. 2003. 19(3):200-4. [QxMD MEDLINE Link].
Dobie DJ, Kivlahan DR, Maynard C, Bush KR, Davis TM, Bradley KA. Posttraumatic stress disorder in female veterans: association with self-reported health problems and functional impairment. Arch Intern Med. 2004 Feb 23. 164(4):394-400. [QxMD MEDLINE Link].
de Beaurepaire R, Lukasiewicz M, Beauverie P, Castéra S, Dagorne O, Espaze R, et al. Comparison of self-reports and biological measures for alcohol, tobacco, and illicit drugs consumption in psychiatric inpatients. Journal of European Psychiatry. November 2007. 22 (8):540-548. [QxMD MEDLINE Link].
Hannuksela ML, Liisanantti MK, Nissinen AE, Savolainen MJ. Biochemical markers of alcoholism. Clin Chem Lab Med. 2007. 45(8):953-61. [QxMD MEDLINE Link]. [Full Text].
Sommers MS, Savage C, Wray J, Dyehouse JM. Laboratory measures of alcohol (ethanol) consumption: strategies to assess drinking patterns with biochemical measures. Biol Res Nurs. 2003 Jan. 4(3):203-17. [QxMD MEDLINE Link].
Bergström JP, Helander A. Clinical Characteristics of Carbohydrate-Deficient Transferrin (%Disialotransferrin) Measured by HPLC: Sensitivity, Specificity, Gender Effects, and Relationship with other Alcohol Biomarkers. Alcohol Alcohol. 2008 Apr 24. [QxMD MEDLINE Link].
Neumann T, Spies C. Use of biomarkers for alcohol use disorders in clinical practice. Addiction. 2003 Dec. 98 Suppl 2:81-91. [QxMD MEDLINE Link].
Bean P. State of the art contemporary biomarkers of alcohol consumption. MLO Med Lab Obs. 2005 Nov. 37(11):10-2, 14, 16-7; quiz 18-9. [QxMD MEDLINE Link].
Hietala J, Koivisto H, Anttila P, Niemelä O. Comparison of the combined marker GGT-CDT and the conventional laboratory markers of alcohol abuse in heavy drinkers, moderate drinkers and abstainers. Alcohol Alcohol. 2006 Sep-Oct. 41(5):528-33. [QxMD MEDLINE Link].
Johnson BA. Medication treatment of different types of alcoholism. Am J Psychiatry. 2010 Jun. 167(6):630-9. [QxMD MEDLINE Link].
Substance Abuse and Mental Health Services Administration. Considerations for the Care and Treatment of Mental and Substance Use Disorders in the COVID-19 Epidemic. Substance Abuse and Mental Health Services Administration. Available at https://www.samhsa.gov/sites/default/files/considerations-care-treatment-mental-substance-use-disorders-covid19.pdf. March 20, 2020; Accessed: March 23, 2020.
US Preventive Services Task Force., Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, et al. Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Nov 13. 320 (18):1899-1909. [QxMD MEDLINE Link].
Reus VI, Fochtmann LJ, Bukstein O, Eyler AE, Hilty DM, Horvitz-Lennon M, et al. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder. Am J Psychiatry. 2018 Jan 1. 175 (1):86-90. [QxMD MEDLINE Link].
Sinclair JD. Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism. Alcohol Alcohol. 2001 Jan-Feb. 36(1):2-10. [QxMD MEDLINE Link].
Rosner S, Hackl-Herrwerth A, Leucht S, Vecchi S, Srisurapanont M, Soyka M. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2010 Dec 8. 12:CD001867. [QxMD MEDLINE Link].
Cassels C. Anticonvulsant Promising for Alcohol Dependence. Medscape Medical News. Available at http://www.medscape.com/viewarticle/813817. Accessed: November 13, 2013.
Mason BJ, Quello S, Goodell V, Shadan F, Kyle M, Begovic A. Gabapentin Treatment for Alcohol Dependence: A Randomized Clinical Trial. JAMA Intern Med. 2013 Nov 4. [QxMD MEDLINE Link].
Nunes EV. Gabapentin: A New Addition to the Armamentarium for Alcohol Dependence?. JAMA Intern Med. 2013 Nov 4. [QxMD MEDLINE Link].
Davenport, L. Antibiotic Cuts Alcohol Cravings, May Enhance Psychotherapy. Medscape Medical News. Available at http://www.medscape.com/viewarticle/845066. Accessed: May 22, 2015.
MacKillop J, Few LR, Stojek MK, Murphy CM, Malutinok SF, Johnson FT, et al. D-cycloserine to enhance extinction of cue-elicited craving for alcohol: a translational approach. Transl Psychiatry. 2015 Apr 7. 5:e544. [QxMD MEDLINE Link].
Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link BG. "A disease like any other"? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. Am J Psychiatry. 2010 Nov. 167(11):1321-30. [QxMD MEDLINE Link].
CDC. Alcohol-Related Disease Impact (ARDI). Centers for Disease Control and Prevention. Available at http://nccd.cdc.gov/DPH_ARDI/default/default.aspx. Accessed: March 4, 2016.
Stahre M, Roeber J, Kanny D, Brewer RD, Zhang X. Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Prev Chronic Dis. 2014 Jun 26. 11:E109. [QxMD MEDLINE Link].
World Health Organization. Global status report on alcohol and health. 2014. Available at http://www.who.int/substance_abuse/publications/global_alcohol_report/msb_gsr_2014_1.pdf?ua=1.
Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005 Feb 10. 352(6):596-607. [QxMD MEDLINE Link].
American Medical Association. Alcoholism in the elderly. Council on Scientific Affairs, American Medical Association. JAMA. 1996 Mar 13. 275(10):797-801. [QxMD MEDLINE Link].
Anton RF, Moak DH, Waid LR, et al. Naltrexone and cognitive behavioral therapy for the treatment of outpatient alcoholics: results of a placebo-controlled trial. Am J Psychiatry. 1999 Nov. 156(11):1758-64. [QxMD MEDLINE Link].
Bigby JA. Substance Abuse Education and General Internal Medicine: A Manual for Faculty. Washington, DC: Society of General Internal Medicine; 1993.
Brauser D. CDC Urges Physicians to Ask About Alcohol. Medscape Medical News. Available at http://www.medscape.com/viewarticle/818793. Accessed: January 16, 214.
Brauser D. Inflammatory Markers May Predict Alcohol Dependence. Medscape Medical News. Available at http://www.medscape.com/viewarticle/836307. Accessed: December 12, 2014.
Brooks M. Alcohol remains a leading cause of premature death. Medscape Medical News. June 27, 2014. [Full Text].
Brooks M. Binge Drinking Boosts Mortality Risk in Older Adults. Medscape Medical News. Mar 3 2014. [Full Text].
CDC. Alcohol Screening and Counseling: An effective but underused health service. Available. Medscape Medical News. Available at http://www.cdc.gov/vitalsigns/alcohol-screening-counseling/index.html.. Accessed: January 16, 214.
Fleming MF, Barry KL, Manwell LB, et al. Brief physician advice for problem alcohol drinkers: A randomized controlled trial in community-based primary care practices. JAMA. 1997. 277:1039-1045. [QxMD MEDLINE Link].
Garbutt JC, Kranzler HR, O'Malley SS. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA. 2005 Apr 6. 293(13):1617-25. [QxMD MEDLINE Link].
Heinz A, Reimold M, Wrase J, et al. Correlation of stable elevations in striatal {micro}-opioid receptor availability in detoxified alcoholic patients with alcohol craving: a positron emission tomography study using carbon 11-labeled carfentanil. Arch Gen Psychiatry. 2005 Jan. 62(1):57-64. [QxMD MEDLINE Link].
Holahan CJ, Schutte KK, Brennan PL, et al. Episodic Heavy Drinking and 20-Year Total Mortality Among Late-Life Moderate Drinkers. Alcohol Clin Exp Res. 2014 Mar 3. [QxMD MEDLINE Link].
Kiefer F, Jahn H, Tarnaske T, et al. Comparing and combining naltrexone and acamprosate in relapse prevention of alcoholism: a double-blind, placebo-controlled study. Arch Gen Psychiatry. 2003 Jan. 60(1):92-9. [QxMD MEDLINE Link].
Malone SM, Iacono WG, McGue M. Drinks of the father: father's maximum number of drinks consumed predicts externalizing disorders, substance use, and substance use disorders in preadolescent and adolescent offspring. Alcohol Clin Exp Res. 2002 Dec. 26(12):1823-32. [QxMD MEDLINE Link].
Mayo-Smith MF, American Society of Addiction Medicine Working Group on Pharmacology. Pharmacological management of alcohol withdrawal: A meta-analysis and evidence-based practice guideline. JAMA. 1997. 278:144-151. [QxMD MEDLINE Link].
Melville N. Confirmed: Gabapentin Improves Alcohol Dependence Outcomes. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/817472. Accessed: December 16, 2013.
Mendelson JH, Mello NK. Medical Diagnosis and Treatment of Alcoholism. New York, NY: McGraw-Hill; 1992.
National Institute on Alcohol Abuse and Alcoholism. Etiology and Natural History of Alcoholism. [Full Text].
NIAAA. Alcohol Involvement in Accidental Death, Homicide, and Suicide. [Full Text].
O'Connor PG, Schottenfeld RS. Patients with alcohol problems. N Engl J Med. 1998 Feb 26. 338(9):592-602. [QxMD MEDLINE Link].
O'Malley SS, Jaffe AJ, Chang G, et al. Six-month follow-up of naltrexone and psychotherapy for alcohol dependence. Arch Gen Psychiatry. 1996 Mar. 53(3):217-24. [QxMD MEDLINE Link].
O'Malley SS, Rounsaville BJ, Farren C, et al. Initial and maintenance naltrexone treatment for alcohol dependence using primary care vs specialty care: a nested sequence of 3 randomized trials. Arch Intern Med. Apr 6 2005. 163(14):1695-704. [QxMD MEDLINE Link].
Piccinelli M, Tessari E, Bortolomasi M, et al. Efficacy of the alcohol use disorders identification test as a screening tool for hazardous alcohol intake and related disorders in primary care: a validity study. BMJ. 1997 Feb 8. 314(7078):420-4. [QxMD MEDLINE Link].
Pletcher MJ, Varosy P, Kiefe CI, et al. Alcohol consumption, binge drinking, and early coronary calcification: findings from the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J Epidemiol. 2005 Mar 1. 161(5):423-33. [QxMD MEDLINE Link].
Room R, Babor T, Rehm J. Alcohol and public health. Lancet. 2005 Feb 5. 365(9458):519-30. [QxMD MEDLINE Link].
Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005 Feb 10. 352(6):596-607. [QxMD MEDLINE Link].
Saitz R, O'Malley SS. Pharmacotherapies for alcohol abuse. Withdrawal and treatment. Med Clin North Am. 1997 Jul. 81(4):881-907. [QxMD MEDLINE Link].
Samet JH, Rollnick S, Barnes H. Beyond CAGE. A brief clinical approach after detection of substance abuse. Arch Intern Med. 1996 Nov 11. 156(20):2287-93. [QxMD MEDLINE Link].
Sigvardsson S, Bohman M, Cloninger CR. Replication of the Stockholm Adoption Study of alcoholism. Confirmatory cross-fostering analysis. Arch Gen Psychiatry. 1996 Aug. 53(8):681-7. [QxMD MEDLINE Link].
Stahre M, Roeber J, Kanny D, Brewer RD, Zhang X. Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Prev Chronic Dis. 2014 Jun 26. 11:E109. [QxMD MEDLINE Link]. [Full Text].
Steinbauer JR, Cantor SB, Holzer CE 3rd, Volk RJ. Ethnic and sex bias in primary care screening tests for alcohol use disorders. Ann Intern Med. 1998 Sep 1. 129(5):353-62. [QxMD MEDLINE Link].
Thun MJ, Peto R, Lopez AD, Monaco JH, Henley SJ, Heath CW Jr. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. N Engl J Med. 1997 Dec 11. 337(24):1705-14. [QxMD MEDLINE Link].
Volpicelli JR, Alterman AI, Hayashida M, O'Brien CP. Naltrexone in the treatment of alcohol dependence. Arch Gen Psychiatry. 1992 Nov. 49(11):876-80. [QxMD MEDLINE Link].
Walden B, McGue M, Lacono WG, et al. Identifying shared environmental contributions to early substance use: the respective roles of peers and parents. J Abnorm Psychol. 2004 Aug. 113(3):440-50. [QxMD MEDLINE Link].
Walsh DC, Hingson RW, Merrigan DM, Levenson SM, Coffman GA, Heeren T, et al. The impact of a physician's warning on recovery after alcoholism treatment. JAMA. 1992 Feb 5. 267(5):663-7. [QxMD MEDLINE Link].
Wilk AI, Jensen NM, Havighurst TC. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med. 1997 May. 12(5):274-83. [QxMD MEDLINE Link].

Media Gallery

Deaths while intoxicated. Data from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

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Table 1. AUDIT Questions and Scoring System

Questions	0 Points	1 Point	2 Points	3 Points	4 Points
1. How often do you have a drink containing alcohol?	Never	Monthly or less	2-4 times a month	2-3 times a week	4 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	7-9	10 or more
3. How often do you have 6 or more drinks on 1 occasion?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
4. How 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
5. How often during the past year have you failed to do what was normally expected of you because of drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
6. How 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
7. How 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
8. How 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
9. Have you or has someone else been injured as a result of your drinking?	No		Yes, but not in the past year		Yes, during the past year
10. Has a relative, friend, or a doctor or other health care worker been concerned about your drinking or suggested you cut down?	No		Yes, but not in the past year		Yes, during the past year

Table 2. Sensitivity and Specificity of Alcohol Biomarkers*

Biomarker	Sensitivity (%)	Specificity (%)
AST	15-69	47-68
ALT	18-58	50-57
GGT	34-85	11-95
MCV	34-89	26-95
CDT	39-94	82-100
CDT + GGT	90 †	98
Alcohol	0-100	0-100
EtG	76-91	77-92
*Values vary considerably according to gender, age, drinking pattern, prevalence of alcohol abuse/dependence, and prevalence of comorbidity, among other factors.^{[40, 6, 41, 43, 44]} † The sensitivity comes from one study in Finland, which uses a special formula. This study needs to be replicated.^[45]