Most people with alcohol use disorder never receive treatment. Drug misuse is identified even less frequently. Primary care is positioned to change this—but only if screening becomes routine.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is the evidence-based framework for making that happen. The research is substantial: brief intervention reduces alcohol consumption in risky drinkers, decreases ED visits, and is cost-effective across settings. One NIAAA-supported study found that combining SBIRT with recovery management made patients nearly four times more likely to start treatment and achieve sustained recovery.
The catch: screening alone doesn't drive outcomes. Patients who screen positive are less likely to receive brief intervention than the screening itself, and even less likely to be referred to treatment. Implementation matters as much as the tools you choose.
Choosing screening tools
For alcohol, the AUDIT (Alcohol Use Disorders Identification Test) is the gold standard. A meta-analysis across 80 studies found sensitivity of 86% and specificity of 87%. The 10-question version takes 2-3 minutes; the 3-question AUDIT-C takes under a minute and performs nearly as well for initial screening (cutoff ≥4 for men, ≥3 for women).
AUDIT scores map directly to clinical action:
- 0-7: Low risk — reinforce healthy behavior
- 8-15: Hazardous use — brief intervention
- 16-19: Harmful use — brief intervention + close monitoring
- 20-40: Probable dependence — referral to treatment
The CAGE is briefer still—four yes/no questions about Cutting down, Annoyance at criticism, Guilt about drinking, and needing an Eye-opener. Two or more positive answers suggest an alcohol problem. CAGE is less sensitive than AUDIT for hazardous drinking and focuses on lifetime rather than current use, but its simplicity makes it memorable and fast.
The MAST (Michigan Alcohol Screening Test) is a longer 22-question instrument that captures more detail about alcohol-related problems and consequences. It's particularly useful when you need a more comprehensive assessment after a positive brief screen.
For drugs, the DAST-10 (Drug Abuse Screening Test) is standard—10 questions, 2-3 minutes. Scores of 1-2 indicate low-level problems; 3-5 suggest moderate issues warranting further evaluation; 6+ indicates substantial problems requiring intensive assessment. An even simpler approach: a single question ("How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?") has 100% sensitivity for drug use disorder at a cutoff of any use.
For multi-substance screening, TAPS (Tobacco, Alcohol, Prescription medication, and other Substances) covers everything in one 2-5 minute instrument. It's slightly less accurate than AUDIT for alcohol but captures a broader range of substances efficiently.
Tiered approach: Start with AUDIT-C or single-question drug screeners for everyone. Administer full AUDIT or DAST-10 only when the brief screen is positive. This minimizes burden while maintaining sensitivity.
The SBIRT workflow
Screening stratifies patients into risk levels. Administer questionnaires via tablet in the waiting room or through a patient portal beforehand—staff reviews scores during rooming so results are ready when you enter.
Brief intervention targets patients with risky but not severe use. This is a 5-15 minute motivational conversation with a specific structure:
1. Raise the subject: "I see from your questionnaire that you've been drinking more than is typically recommended. Can we talk about this?"
2. Provide feedback: Share screening results in neutral, non-judgmental terms. Compare to recommended limits. Explain health risks relevant to this patient.
3. Assess readiness: "On a scale of 1-10, how ready are you to make a change in your drinking?"
4. Enhance motivation: Explore pros and cons of current use. Elicit the patient's own reasons for change rather than lecturing.
5. Negotiate a plan: If ready, collaboratively set a specific, measurable goal. If not ready, leave the door open for future discussion.
6. Arrange follow-up: Schedule reassessment in 2-4 weeks.
Even very brief conversations under 5 minutes have measurable effects on alcohol use. Something is better than nothing.
Referral to treatment applies to probable substance use disorders (AUDIT 20+, DAST 6+, or clinical judgment). Frame it as a medical issue: "Based on your responses and our conversation, I'm concerned you may have an alcohol use disorder. This is a medical condition that responds to treatment."
The warm handoff matters: make the appointment while the patient is present when possible. Many patients never show for initial appointments—a follow-up call from your staff significantly improves show rates. Address barriers directly: insurance, transportation, childcare, work schedules.
Integration with mental health screening
Substance use and mental health conditions frequently co-occur: depression with alcohol use disorder, anxiety with benzodiazepine misuse, PTSD with substance use broadly. Screening for one without the other misses important clinical information.
The simplest approach is sequential: screen for mental health with the PHQ-9 and GAD-7, then screen for substances with AUDIT/DAST or CAGE/MAST. Alternatively, screen everyone for mental health and add substance screening when mental health screens positive (or vice versa).
When both concerns are identified, assess the interaction: Does substance use cause psychiatric symptoms? Do psychiatric symptoms drive substance use? Are they independent? Integrated treatment addressing both is more effective than treating one while ignoring the other.
Making it work
Time constraints are the top objection, but they're solvable. Pre-visit screening eliminates administration time—you're reviewing completed scores, not administering tests. Brief tools like AUDIT-C and single-question drug screeners minimize burden. Team-based care lets medical assistants handle screening while clinicians focus on interpretation and intervention.
Provider discomfort discussing substance use is common but addressable through training and practice. The scripted approach above helps—you're not improvising, you're following a structure that's been validated across thousands of encounters.
Patient honesty varies due to stigma, but validated instruments detect problems even when patients minimize. Self-administered questionnaires increase disclosure compared to face-to-face questioning. Normalizing screening ("We ask all patients") reduces the sense of being singled out.
Limited treatment resources present the hardest problem. Build referral relationships before crises arise. Know telehealth options. Consider medication-assisted treatment in primary care—buprenorphine prescribing expands treatment capacity significantly. When specialty treatment isn't accessible, brief intervention and harm reduction still help.
---
Universal screening with validated tools catches substance use problems that clinical judgment misses. The CAGE and MAST provide fast, validated alcohol screening, and the SBIRT framework turns positive screens into action—catching risky use early, before it becomes a disorder.