Drinking Problems. How to Diagnose

An accurate diagnosis of alcohol abuse or dependence requires a thorough medical history. Medical markers such as gastrointestinal problems or elevated liver enzymes are cause for suspicion but are not diagnostic. For example, using a GGT level higher than 40 to detect alcohol problems in a primary care population results in a sensitivity of 44 to 54 percent and a specificity of 80 to 84 percent.17 In contrast, a CAGE questionnaire with three or more positive responses is 100 percent sensitive and 81 percent specific for current alcohol dependence.18

NIAAA categorizes heavy drinkers into three groups: at-risk drinkers, problem drinkers (parallel to the DSM-IV diagnosis of "alcohol abuse"), and alcohol-dependent drinkers (parallel to the DSM-IV diagnosis of "alcohol dependence"). Table 8 describes the NIAAA assessment of alcohol-related problems.12

At-risk Drinkers
In the absence of medical, social or psychologic consequences of drinking, men who have more than 14 drinks per week or more than four drinks per occasion are considered "at risk" for developing problems related to drinking. Similarly, women who have more than 11 drinks per week or more than three drinks per occasion are "at risk." Because some drinkers significantly underreport their alcohol use, physicians should define patients as "at risk" when they have a positive CAGE score or a personal or family history of alcohol-related problems (Table 8).

Problem Drinkers
Patients who have current alcohol-related medical, family, social, employment, legal or emotional problems are considered "problem drinkers" regardless of their drinking patterns or responses to the CAGE questions (Table 8). Typically, these patients score 1 or 2 on the CAGE questionnaire and drink above "at-risk" levels.

Alcohol-dependent Drinkers
Patients drinking above the "at-risk" level who have CAGE scores of 3 or 4 should be questioned about their drinking compulsions, tolerance to alcohol and withdrawal symptoms (Table 2). Those who display these traits are considered "alcohol dependent."