3. Identification and brief interventions
How to use validated tools to identify health risk from alcohol use, deliver brief interventions to help people reduce their drinking or refer those with possible dependence to specialist assessment.
Staff in health and social care, the criminal justice system and community and voluntary sector services in both NHS and non-NHS settings should routinely identify people whose health is at risk from their alcohol use. To do this, they should use a validated screening tool such as the alcohol use disorders identification test (AUDIT) or a short-form of it.
Health and care staff should offer an alcohol brief intervention (ABI) to people whose alcohol use significantly increases risks to health (hazardous or ‘increasing risk’ drinking) or is likely to be harming their health (harmful or ‘higher-risk’ drinking) but who are not dependent on alcohol.
Health and care staff should offer a referral for specialist alcohol assessment to anyone with alcohol dependence or possible alcohol dependence. They should also offer a referral for specialist alcohol assessment to people who are drinking at harmful (higher-risk) levels and have alcohol-related physical or mental health conditions.
Health and care staff should not offer an ABI to people who are identified as possibly dependent, but should offer them a referral for a specialist alcohol assessment.
These guidelines are mainly for treating people with alcohol dependence and people drinking at harmful levels who are experiencing alcohol-related physical health, mental health and social problems. But this chapter provides guidance on identifying and responding to the full spectrum of alcohol use disorders.
In these guidelines, we use the term ‘alcohol use disorder’ (AUD) to include any pattern of alcohol use that significantly increases risks to health, either harmful (higher-risk) drinking or alcohol dependence. See section 3.3.2 for guidance on these categories.
People with AUD use many different healthcare services and this gives health and care staff an important opportunity to identify and support them. The report Alcohol-attributable fractions for England lists alcohol use as a significant causal factor in over 60 medical conditions. Around a quarter of adults in the UK are estimated to drink in a way that incurs lifetime risk of an alcohol-related condition.
Most people who drink above low-risk levels or have an AUD do not need specialist treatment but may benefit from ABI, sometimes known as screening and brief interventions (see definition of brief interventions in the glossary). In England, the term ‘identification and brief advice’ (or IBA) is commonly used to describe alcohol risk screening and brief intervention.
3.3.1 Settings for AUD identification
Identification of AUDs should take place across a range of settings, so that people are routinely asked about their alcohol use. Primary care, hospitals and mental health settings are particularly important for identifying alcohol-related risk and providing brief interventions or referring people for specialist alcohol assessment where appropriate.
Relevant health, social care and criminal justice services should include alcohol risk identification (screening) tools in standard assessment practices where possible. Where AUD identification tools are not included in standard assessments, practitioners should be trained and supported to ask the appropriate questions about alcohol use and provide simple brief interventions.
Asking everybody if they are willing to answer some questions about their alcohol use normalises the subject and maximises the chance of identifying alcohol health risk where there are no obvious signs or symptoms.
3.3.2 AUDIT scores
AUDIT is the gold standard for AUD identification. In the UK, services should use the UK version that measures alcohol use in ‘units’ in questions 2 and 3. Versions of AUDIT from many other countries measure alcohol use using ‘standard drinks’. This is not the usual terminology in the UK and is not likely to be readily understood by long-term UK residents or easily compared to UK consumption guidelines.
The AUDIT does not give a clinical diagnosis but indicates which alcohol risk category a person falls into based on their score.
Possible scores for the full 10 question AUDIT are:
- low-risk: no current AUD
- hazardous (increasing-risk) drinking
- harmful (higher-risk) drinking
- possible alcohol dependence
0 to 7: low-risk - no current AUD
A score between 0 and 7 indicates that the person is drinking at a level that does not significantly increase lifetime risk of alcohol-related ill health.
8 to 15: hazardous (increasing-risk) drinking
A score between 8 and 15 indicates that the person is increasing their risk of a range of alcohol-related issues. You should offer them brief intervention.
16 to 19: harmful (higher-risk) drinking
A score between 16 and 19 indicates that the person is drinking in a way that presents a higher lifetime risk of an alcohol-related condition and is likely already to be causing alcohol-related harm. You should offer them brief intervention.
Some people who score between 16 and 19 will need a referral for specialist alcohol assessment or to their GP (see ‘Using clinical judgement or knowledge of the person’ below). People drinking at this harmful level who have symptoms of alcohol dependence or alcohol-related physical health or mental health conditions should be made aware of the link between alcohol and their condition. You should offer them referral for specialist alcohol assessment or to their GP.
20 or more: possible alcohol dependence
A score of 20 or more indicates that the person is likely to have at least some level of alcohol dependence. You should offer them referral for specialist alcohol assessment. AUDIT is not a diagnostic tool and you should not indicate a diagnosis of dependence based on AUDIT score alone. Diagnosis of alcohol dependence requires assessment by a clinician with appropriate specialist skills.
Using clinical judgement or knowledge of the person
You should use AUDIT scores to guide appropriate interventions and support, but the scores should not override clinical judgement or your knowledge of the person in individual cases. In some cases, it may be appropriate to offer a referral to a specialist service for people whose AUDIT score is below 20. For example, people:
- who have or have recently had symptoms of alcohol dependence
- with significant alcohol-related physical health conditions such as liver disease or mental health conditions such as depressive disorder
- with alcohol-related problems who have already tried to cut down their drinking and have not been able to
3.3.3 Short-form validated screening questionnaires
In a variety of settings, where time is limited, you can use short-form validated screening questionnaires such as the following.
These screens consist of selected questions from the AUDIT questionnaire and can be used to identify people who may have an AUD. A positive screen (for example, an AUDIT-C score of 5 or more) should prompt you to complete the full AUDIT questionnaire. The full AUDIT score will identify which people could benefit from brief interventions and which people might need specialist alcohol assessment or a referral to their GP.
AUDIT-C
Alcohol use disorders identification test for consumption (AUDIT-C) on the Alcohol use screening tests page is a tool that consists of the 3 consumption questions from the full AUDIT. You can use AUDIT-C to quickly identify whether the person is at risk of alcohol harm. If the person’s AUDIT-C score is 5 or more, you should use the full AUDIT questionnaire with them, because the score suggests they are drinking at a level that could cause or is causing harm to themselves or others.
ASSIST-Lite
Alcohol, Smoking and Substance Involvement Screening Tool - Lite (ASSIST-Lite) is a short screening tool for use with adults (aged 18 and over). It can help to identify alcohol, drug and tobacco smoking-related risks. You can use it during assessments, care planning, one-to-one or review sessions. There is one version of the tool for mental health services and another for other health and social care services. Both versions include the 3 AUDIT-C questions described above.
FAST
Fast alcohol screening test (FAST) on the Alcohol use screening tests page is a tool consisting of a subset of 4 questions from the full AUDIT, asked in 2 stages. FAST was initially developed for use in emergency departments but can be used in a variety of health and social care settings.
M-SASQ
Modified-single alcohol screening questionnaire (M-SASQ) on the Alcohol use screening tests page is a test to quickly assess people at risk of alcohol harm. It comprises one question from the full AUDIT and was developed for use in emergency departments but can be used in other settings where time is limited.
3.3.4 Routine identification of alcohol health risk
All relevant services should routinely identify alcohol health risk, using a validated tool such as AUDIT. For example, you should discuss alcohol health risks with patients during new registrations or when screening for other conditions.
There is national guidance and support for delivering ABI in each of the UK nations. In some parts of the UK, using AUDIT to identify alcohol health risk is a requirement for at-risk patient groups as part of primary and secondary care contracts and the NHS Health Check. Large-scale provision of ABI is part of Scotland’s national Alcohol Framework 2018, which was reviewed by Audit Scotland in 2024 with recommendations for the framework to be refreshed.
Health and social care services should use initiatives like Making Every Contact Count (MECC) to identify AUDs and offer ABIs. Health and social care services should ensure that effective pathways are in place, including referral to services that can provide specialist alcohol assessment and treatment or other types of care where needed.
Making effective identification an integral part of your service provision will include organisational commitment, leadership and accountability. Staff expected to deliver ABI will require training in brief intervention approaches. Services should monitor their brief intervention provision to ensure it is taking place and that interventions offered are appropriate to the level of risk identified. Integration of AUDIT questions and scores into electronic assessment and record systems can be particularly valuable.
Digital resources that use AUDIT can play a role in supporting identification, but you should consider and implement them carefully. Read more about digital interventions in section 5.7.3 in chapter 5 on psychosocial interventions. There is emerging evidence that apps for mobile devices can be effective in reducing consumption among people who drink at hazardous (increasing-risk) or harmful (higher-risk) levels (see resources section at the end for an example of digital AUDIT based tools).
3.4.1 The aim of ABIs in general settings
There is a long-standing evidence base (see The public health burden of alcohol: evidence review) for the effectiveness of ABIs in reducing alcohol consumption among people who do not need alcohol treatment but whose drinking may be a risk to their long-term health and wellbeing. So, the main goal of using ABIs in general and non-specialist settings is to identify and engage with this group, which will include most people drinking at hazardous (increasing-risk) and harmful (higher-risk) levels.
ABIs focus on giving people information about risk and motivating them to reduce their drinking towards lower risk levels. Although identifying dependence is not the main purpose of ABIs, they provide an important opportunity to identify and refer people with alcohol dependence and anyone drinking at harmful (higher-risk) levels who may need specialist assessment or intervention.
3.4.2 Delivering appropriate ABI approaches
Simple alcohol brief intervention (brief advice in England) is a general approach to opportunistic brief interventions that can be easily provided in a few minutes by non-specialist staff after minimal training in a wide range of settings.
People who drink at hazardous (increasing-risk) levels usually do not currently have significant alcohol-related problems, so are well-suited to simple ABI approaches. Most people drinking at harmful (higher-risk) levels do not need specialist assessment or support and will also benefit from brief interventions.
ABIs are non-treatment interventions that are effective in prompting people to reduce their drinking on their own. Simple ABI typically involves a brief conversation about alcohol use, which:
- gives feedback on the person’s level of risk (for example, explaining the meaning of the AUDIT score) and if appropriate, encouraging them to talk about the potential benefits from reducing their regular consumption
- identifying the person’s alcohol reduction goals and basic strategies to support them
- providing the person with information to take away and consider in their own time (for example, see the alcohol advice and information leaflet in resources section)
It may be helpful for staff to be familiar with other simple motivational components such as those set out by the FRAMES approach (feedback, responsibility, advice, menu, empathy, self-efficacy). See definition of FRAMES in the glossary.
You should deliver ABIs in a way that aims to make the person feel encouraged and supported by using a motivational, person-centred approach. Staff delivering ABIs should be trained in a way that incorporates the basic principles of motivational interventions. You can read more about motivational interventions in section 5.5.6.
3.4.3 Referral for people who drink at harmful levels or with possible alcohol dependence
People with AUDIT score 16 to 19
You should offer ABI to people who regularly drink at harmful (higher-risk) levels (AUDIT score of 16 to 19). For people with harmful patterns of drinking, who have an alcohol-related health condition (such as liver disease, cardiovascular disease or depressive disorder), other substance use conditions or other significant health needs, you should also consider offering:
- referral for specialist alcohol assessment (see chapter 4 on assessment and treatment and recovery planning)
- information about alcohol treatment options
- referral to their GP
- referral to additional support where there are any signs of risk or complexity
People with AUDIT score 20 or more
You should not offer ABI to people you identify as possibly alcohol dependent (AUDIT score of 20 or more), but you should offer them a referral for specialist alcohol assessment. If the person is in the community, you should offer them a referral to the local community alcohol treatment service and if they are an inpatient in hospital, you should refer them to an alcohol specialist in the hospital. This is particularly important for people whose AUDIT scores are 30 and above.
If you refer a person for specialist assessment, you should do this in an encouraging way, listening to their concerns and discussing them. The person might feel stigma or fear about going to an alcohol treatment service, so it’s important to be as supportive as possible when you refer them. Active referral, whereby the treatment service is expecting the person, is more likely to be taken up than if the person is expected to self-refer (signposted).
Where a person does not want to engage in treatment, you should offer information about services and try to find future opportunities to offer a referral or follow up on their alcohol use and any related problems.
It is not likely to be necessary, practical nor cost-effective to evaluate ABI provision by following up recipients to see if their alcohol use has changed.
Evidence shows that ABIs are effective in reducing consumption in a proportion of people who drink at hazardous (increasing-risk) and harmful (higher-risk) levels if the intervention is appropriately delivered (for more information, see The public health burden of alcohol: evidence review). So, effectiveness of ABI programmes is more likely to be optimised by evaluating the scale and quality of delivery and taking action to improve it, where appropriate. For example, you can do this by monitoring data on the proportion of a target group tested with AUDIT and the appropriateness of the intervention offered, based on the AUDIT score.
The Alcohol use screening tests page contains the UK versions of the AUDIT and short-form AUDIT tools that can be printed and used by or with people to identify their risk of alcohol-related harm. There is also an advice and information leaflet for ABI recipients and a link to free e-learning about providing AUDIT screening and simple brief advice in various settings.
AUDIT translations has printable versions of the AUDIT, translated into over 60 languages, including Turkish, Greek, Hindi, German, Dutch, Polish, Japanese, French, Portuguese, Spanish, Danish, Flemish, Bulgarian, Chinese, Italian and Nigerian dialects.
Alcohol Change UK’s Check your drinking interactive tool is a free to use interactive online AUDIT form that identifies a person’s level of risk and provides advice on cutting down or seeking specialist assessment.