Table C.1 Quick guide to alcohol units (Cheryl Kipping).
Drink
Beers (lager, bitter)
Regular lager
E.g. Carlsberg, Carling, Foster’s
Premium lager
E.g. Budweiser, Kronenbourg, Stella, Grolsch, Peroni, Becks
Super Strength Lager
E.g. Skol Super, Tennent’s Super, Special Brew, Kestrel
Bitter
E.g. Tetley, John Smith’s
Guinness
Ciders
Regular
E.g. Magner’s, Bulmer’s
Strongbow
Scrumpy Jack
Strong
E.g. Diamond White, White Star
Wine commonly 12–13.5%
Small glass
Large glass
Bottle
Spirits usually 37.5–40% ABV
Gin, vodka, whisky, brandy
Other
Alcopops
E.g. Bacardi Breezer, WKD, Smirnoff Ice
% ABV
4%
5%
9%
3.8%
4.2%
4.5%
5.3%
6%
7.5%
12%
37.5%
4%
Amount
Units
440 ml can
1 pint
275 ml bottle
330 ml bottle
440 ml can
1 pint
500 ml can
1.8
2.3
1.4
1.7
2.2
2.9
4.5
440 ml can
1 pint
440 ml can
1 pint
1.7
2.2
1.8
2.4
440 ml can
1 pint/568 ml bottle
440 ml can
2 litre bottle
500 ml
275 ml bottle
500 ml can
2
2.6
2.3
10.6
3
2
3.8
175 ml
250 ml
750 ml
2.1
3
9
25 ml (single) measure
75 cl bottle
275 ml bottle
1
28–30
1.1
The % ABV for other drinks is: Martini 15%, Baileys 17%, Sherry 17.5%, Tia Maria 20%, Port 20%
• This is a rough, practical guide to the number of units of alcohol in common drinks (units rounded to the nearest 0.1u)
• Strength varies between brands - always check % (Alcohol By Volume; ABV)
volume (litres) × ABV (%)
• To more accurately calculate units =
1000
Psychiatry: Breaking the ICE – Introductions, Common Tasks and Emergencies for Trainees, First Edition.
Edited by Sarah Stringer, Juliet Hurn and Anna M Burnside.
© 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.
Companion Website: www.psychiatryice.com
Table C.2 Alcohol Use Disorders Identification Test (AUDIT) questionnaire.
1. How often do you have a drink containing alcohol?
◽
◽
◽
◽
◽
(0) Never [Skip to Qs 9–10]
(1) Monthly or less
(2) 2 to 4 times a month
(3) 2 to 3 times a week
(4) 4 or more times a week
2. How many drinks containing alcohol do you have on a
typical day when you are drinking?
(0) 1 or 2
(1) 3 or 4
(2) 5 or 6
(3) 7, 8, or 9
(4) 10 or more
◽
◽
◽
◽
◽
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
◽
◽
◽
◽
◽
◽
◽
◽
◽
◽
7. How often during the last year have you had a
feeling of guilt or remorse after drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
3. How often do you have six or more drinks on one
occasion?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) 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?
◽
◽
◽
◽
◽
8. How often during the last year have you been
unable to remember what happened the night
before because you had been drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
◽
◽
◽
◽
◽
Skip to Questions 9 and 10 if Total Score for Questions 2 and
3=0
4. How often during the last year have you found that
9. Have you or someone else been injured as a
you were not able to stop drinking once you had started? result of your drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) 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?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
Total score:
◽
◽
◽
◽
◽
(0) No
◽
(2) Yes, but not in the last year ◽
(4) Yes, during the last year
◽
10. Has a relative or friend or a doctor or another
health worker been concerned about your
drinking or suggested you cut down?
(0) No
◽
(2) Yes, but not in the last year ◽
(4) Yes, during the last year
◽
Table C.2 Alcohol Use Disorders Identification Test (AUDIT) questionnaire. (continued)
Audit Score Guidance
AUDIT score
Drinking category∗
Intervention
0–7
Lower risk
8–15
Increasing risk (hazardous
use)
16–19
Higher risk (harmful use)
e.g. women 35+u or men
50+u/week
Possible dependence (very
likely with higher
scores)
No specific intervention.
Consider offering information and promote continued drinking within
‘safe’ levels.
If working towards abstinence, encourage continued reduction.
Above recommended levels
Simple brief advice: provide information.
Encourage to reduce
Extended brief intervention.
Offer sessions to help reduce drinking and risk-taking behaviour.
Focus on enhancing motivation to change.
Community - complete SADQ (Severity of Alcohol Dependence
Questionnaire, p508)
Inpatient – monitor using CIWA-Ar (withdrawal assessment scale, p509).
Consider specialist advice and referral to alcohol service if person wants to
stop drinking.
20–40
∗ Thresholds
are lower for some groups (e.g. elderly, some BME, SMI) - consider the next level up if concerned.
• Read questions as written. Record answers carefully. Begin the AUDIT by saying, “Now I am going to ask you some
questions about your use of alcoholic beverages during this past year.”
• Explain what is meant by ‘alcoholic beverages’ by using local examples of beer, wine, vodka, etc. Code answers in terms
of ‘standard drinks’. Place the correct answer in the box at the right.
Source: Babor, T.F., Higgins-Biddle, J.C., Saunders, J.B. and Moterio, M.G. (2001). The Alcohol Use Disorders Identification
Test: Guidelines for use in primary care (2nd edition). World Health Organisation. Reproduced with permission of the World
Health Organisation.
Table C.3 Severity of Alcohol Dependence Questionnaire (SADQ).
SADQ
Please recall a recent month when you were drinking in a way that was typical of a heavy drinking period for you. Please
fill in the month and year:
Month....
Year.....
We want to know more about your drinking during this time and how often you experienced certain feelings. Please put
a tick to show how frequently each of the following statements applied to you during this typical period of drinking.
Question
Score
Almost
never
0
Sometimes
Often
1
2
Nearly
always
3
The day after drinking alcohol …
1. I woke up feeling sweaty
2. My hands shook first thing in the morning
3. My whole body shook violently first thing in the morning
4. I woke up absolutely drenched in sweat
5. I dreaded waking up in the morning
6. I was frightened of meeting people first thing in the
morning
7. I felt on the edge of despair when I woke up
8. I felt very frightened when I woke up
9. I liked to have an alcoholic drink in the morning
10. I always gulped down my first few morning drink(s) as
quickly as possible
11. I drank in the morning to get rid of shakes
12. I had a very strong craving for a drink when I awoke
13. I drank more than 1/4 bottle of spirits or 4 pints of beer
or 1 bottle of wine a day
14. I drank more than 1/2 bottle of spirits or 8 pints of beer
or 2 bottles of wine a day
15. I drank more than 1 bottle of spirits or 15 pints of beer
or 4 bottles of wine a day
16. I drank more than 2 bottles of spirits or 15 pints of beer
or 8 bottles of wine a day
Imagine the following situation: you have been completely off drink for a few weeks and then you drink heavily for two
days.
How would you feel the morning after those drinking days?
(If person has not been abstinent for a period of 2 weeks, score 3 for remaining items).
17. I would start to sweat
18. My hands would shake
19. My body would shake
20. I would be craving a drink
Total score
≤15
16–30
31+
Mild dependence
Moderate dependence
Severe dependence
Source: Adapted from Stockwell, T., Murphy, D. & Hodgson, R. (1983). The severity of alcohol dependence questionnaire: Its
use, reliability and validity. British Journal of Addiction, 78(2), 45–156. Free to reproduce.
Table C.4 Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar).
Patient
Date
Time
Heart rate
BP
Nausea & vomiting
Do you feel sick to your stomach?
Have you vomited?
Observation
Tactile disturbances
Have you any itching, pins and needles sensations, any
burning, any numbness, or do you feel bugs crawling on or
under your skin?
Observation
0
1
2
3
4
5
6
7
No nausea or vomiting
Mild nausea, no vomiting
Intermittent nausea + dry heaves
2
3
Constant nausea, frequent dry heaves + vomiting
4
5
6
7
Tremor
Arms extended and fingers spread apart.
Observation
0
1
2
3
4
5
6
7
No tremor
Not visible, but can be felt fingertip to fingertip
Moderate, with patient’s arms extended
Severe, even with arms not extended
Paroxysmal sweats
Observation
0
1
2
3
4
5
6
7
0
1
No sweat visible
Barely perceptible sweating, palms moist
Beads of sweat obvious on forehead
Drenching sweats
None
Very mild itching, pins and needles, burning or
numbness
Mild itching, pins and needles, burning or numbness
Moderate itching, pins and needles, burning or
numbness
Moderately severe hallucinations
Severe hallucinations
Extremely severe hallucinations
Continuous hallucinations
Auditory disturbances
Are you more aware of sounds around you? Are they
harsh? Do they frighten you? Are you hearing anything that
is disturbing to you? Are you hearing frightening things you
know are not there?
Observation
0
1
2
3
4
5
6
7
Not present
Very mild harshness or ability to frighten
Mild harshness or ability to frighten
Moderate harshness or ability to frighten
Moderately severe hallucinations
Severe hallucinations
Extremely severe hallucinations
Continuous hallucinations
Visual disturbances
Does the light appear to be too bright? Is its colour
different? Does it hurt your eyes? Are you seeing anything
that is disturbing to you? Are you seeing things you know
are not there?
Observation
0
1
2
3
4
5
6
7
Not present
Very mild sensitivity
Mild sensitivity
Moderate sensitivity
Moderately severe hallucinations
Severe hallucinations
Extremely severe hallucinations
Continuous hallucinations
Table C.4 Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). (continued)
Anxiety
Do you feel nervous?
Observation
0
1
2
3
4
5
6
7
No anxiety, at ease
Mildly anxious
Moderately anxious, or guarded, so anxiety is
inferred
Acute panic
Headache, fullness in head
Ask, Does your head feel different? Does it feel like there is
a band around your head?
Do not rate for dizziness or light-headedness. Otherwise,
rate severity.
0
1
2
3
4
5
6
7
Not present
Very mild
Mild
Moderate
Moderately severe
Severe
Very severe
Extremely severe
Agitation
Observation
Orientation and clouding of sensorium
What day is this? Where are you? Who am I?
0
1
2
3
4
5
6
7
0
1
2
3
4
Normal activity
Somewhat more than normal activity
Moderately fidgety and restless
Oriented and can do serial additions
Cannot do serial additions or is uncertain about date
Disoriented for date by no more than 2 calendar days
Disoriented for date by more than 2 calendar days
Disoriented for place/or person
Paces back and forth during most of the
interview, or constantly thrashes about
Total CIWA-Ar score:
Rater’s initials:
Maximum possible score 67
Scores:
≤ 10 – mild withdrawal (does not need additional medication)
≤ 15 – moderate withdrawal
> 15 – severe withdrawal
Source: Sullivan, J.T., Sykora, K., Schneiderman, J., Naranjo, C.A., & Sellers, E.M. (1989) Assessment of alcohol withdrawal:
The revised Clinical Institute Withdrawal Assessment of Alcohol scale (CIWA-Ar). British Journal of Addiction, 84: 1353–1357.
Free to reproduce.
Table C.5 Clinical Opiate Withdrawal Scale (COWS).
Patient name:
Time of observation/Score
Resting pulse rate: record beats per minute after
patient is sitting or lying for 1 minute
0 = ≤ 80
1 = 81–100
2 = 101–120
4 = >120
Sweating: over past 1/2 hour, not accounted for by
room temperature/patient activity
0 = no report of chills or flushing
1 = subjective report of chills or flushing
2 = flushed or observable moistness on face
3 = beads of sweat on brow or face
4 = sweat streaming off face
Restlessness: observation during assessment
0 = able to sit still
1 = reports difficulty sitting still, but is able to do so
3 = frequent shifting or extraneous movement of
legs/arms
4 = unable to sit still for more than a few seconds
Pupil size
0 = pupils pinned or normal size for room light
1 = pupils possibly larger than normal for room light
2 = pupils moderately dilated
5 = pupils so dilated that only the rim of the iris is visible
Bone or joint aches: If patient was having pain
previously, only the additional component attributed to
opiate withdrawal is scored.
0 = not present
1 = mild diffuse discomfort
2 = patient reports severe diffuse aching of
joints/muscles
4 = patient is rubbing joints or muscles and is unable to
sit still because of discomfort
Runny nose or tearing: Not accounted for by cold
symptoms or allergies
0 = not present
1 = nasal stuffiness or unusually moist eyes
2 = nose running or tearing
4 = nose constantly running or tears streaming down
cheeks
GI upset: over last 1/2 hour
0 = no GI symptoms
1 = stomach cramps
2 = nausea or loose stool
3 = vomiting or diarrhoea
5 = multiple episodes of diarrhoea or vomiting
(continued overleaf )
Table C.5 (continued)
Patient name:
Time of observation/Score
Tremor: observation of outstretched hands
0 = no tremor
1 = tremor can be felt, but not observed
2 = slight tremor observable
4 = gross tremor or muscle twitching
Yawning: observation during assessment
0 = no yawning
1 = yawning once or twice during assessment
2 = yawning three or more times during assessment
4 = yawning several times/minute
Anxiety or Irritability
0 = none
1 = patient reports increasing irritability or anxiousness
2 = patient obviously irritable/anxious
4 = patient so irritable or anxious that participation in
the assessment is difficult
Gooseflesh skin
0 = skin is smooth
3 = piloerection of skin can be felt or hairs standing up
on arms
5 = prominent piloerection
TOTAL SCORE
Observer’s initials
Total score
Withdrawal level
5–12
13–24
25–36
> 36
Mild
Moderate
Moderately severe
Severe
• For each item, write in the number that best describes the patient’s signs or symptom
• Rate on just the apparent relationship to opiate withdrawal. For example, if heart rate is increased because the patient
was jogging just prior to assessment, the increase pulse rate would not add to the score.
Source: Wesson, D.R. & Ling, W (2003). The clinical opiate withdrawal scale (COWS) Journal of Psychoactive Drugs, 35,
253–259. Free to reproduce.
Table C.6 Common illicit drugs summary.
Drug Examples
Intoxication
Withdrawal
Notes
Cannabis (weed,
skunk, hash, ganja)
Relaxation, sedation
Euphoria, giggling
Anxiety, paranoia
Perceptual/time distortion
Nausea/vomiting
Hunger (“the munchies”)
Dry mouth, bloodshot eyes
↓ Attention, short-term memory
↓ Reactions, coordination
↓ BP
↑ HR
Energy, euphoria, alertness
Overactive, agitation
Insomnia
↓ Appetite
↑Confidence
↑Impulsivity
↑HR, BP
Arrhythmia
Relaxation/sedation
Ataxia, slurred speech
↓ RR, HR, BP
Respiratory arrest/coma
Irritability, anxiety
Restlessness
Insomnia/vivid dreams
(can last three
weeks)
Shaky, sweaty; cold
chills
↓ Appetite
Stomach pains
Can trigger psychosis.
Usually smoked,
sometimes
eaten/drunk.
Skunk is a particularly
potent form.
‘Crash’: dysphoria,
fatigue
Can trigger psychosis.
Khat – leaves,
commonly chewed in
Somali/Yemeni
communities. Poor
dentition common.
Anxiety, panic
Insomnia
Agitation
Tremor
Headache
Nausea/vomiting
↑HR
Fits
Agitation, anxiety
Abdominal/bladder
pain (lose analgesia)
Deaths from respiratory
depression, especially
in combination with
alcohol/opiates.
Often used to cope with
withdrawal from
other drugs.
See p254–255
Chronic use: bladder
problems
Urinary frequency,
haematuria
Accidental injury during
intoxication
(anaesthetic and
psychotic effects)
No clear withdrawal
syndrome
Deaths related to
dehydration,
hyperthermia and/or
excessive fluid intake
Stimulants
Amphetamines
(speed)
Cocaine (coke)
Crack cocaine
Khat
Benzodiazepines
(downers, jellies)
Ketamine
(K, special K, super K)
Ecstasy (MDMA, E)
Euphoria, stimulation, anxiety
Synaesthesia, dissociation
Floating/“spiritual” experiences
Psychosis
↑HR, BP,
↓ RR, GCS
Dilated pupils
Ataxia
Nausea/vomiting
Dizziness, diplopia
Insomnia
Confusion
Inability to speak/move
Stimulant effects
Empathy, talkativeness
Overactivity
Teeth-grinding
Nausea/vomiting
Sweating
↑Temperature
Dehydration
Table C.6 (continued)
Drug Examples
Intoxication
Withdrawal
Hallucinogens
E.g. lysergic acid
diethylamide (LSD;
acid), magic
mushrooms
Solvents
E.g. aerosols (glue,
gas)
Synaesthesia
Depersonalisation/derealisation
Illusions, hallucinations
Anxiety
No clear withdrawal
syndrome
Euphoria
Ataxia, dizziness
Disinhibition
Confusion
Hallucinations
Nausea/vomiting
Coma
Headaches
Fits
• For opiates, see Ch.41
• For GBL/GHB, see p464
Notes
Often inhaled by
teenagers, e.g. from a
plastic bag/clothing
Deaths usually from
asphyxiation of vomit