Differences in performance of screening instruments for problem drinking among blacks, whites and Hispanics in an emergency room population

Single episode of alcohol use resulting in injury: a cross-sectional study in 21 countries

OBJECTIVE

To examine the empirical basis for including the diagnostic category of "a single episode of harmful substance use" in the 11th revision of the International statistical classification of diseases and related health problems (ICD-11).

METHODS

We used data on patients admitted to emergency departments in 21 countries with alcohol-related injuries (i.e. with drinking within the preceding six hours) who had no sign of alcohol intoxication or withdrawal, no alcohol in blood and no sign of alcohol dependence or harmful drinking as described in the ICD-10. We obtained data on alcohol-related injuries, the patient's causal attribution of injury to drinking, the alcohol amount consumed, blood alcohol concentration and usual drinking pattern. Patients with and without alcohol dependence or harmful drinking were compared.

FINDINGS

We included a representative sample of 18 369 patients. After adjustment for unequal sampling, 18.8% reported drinking in the six hours before injury and 47.1% of these attributed their injury to drinking; 16.3% of those reporting drinking and 10.3% of those attributing their injury to drinking were not alcohol dependent or harmful drinkers. The majority of these last two groups reported never having had five or more drinks on one occasion during the last year and had a blood alcohol concentration less than 0.05%.

CONCLUSION

Some individuals attending emergency departments had alcohol-attributable injuries due to a single episode of drinking but had no history of harmful use or dependence. These findings highlight the public health relevance of including the new diagnostic category in the ICD-11.

A path model of different forms of impulsivity with externalizing and internalizing psychopathology: Towards greater specificity

OBJECTIVES

A growing empirical literature indicates that emotion-related impulsivity (compared to impulsivity that is unrelated to emotion) is particularly relevant for understanding a broad range of psychopathologies. Recent work, however, has differentiated two forms of emotion-related impulsivity: A factor termed Pervasive Influence of Feelings captures tendencies for emotions (mostly negative emotions) to quickly shape thoughts, and a factor termed Feelings Trigger Action captures tendencies for positive and negative emotions to quickly and reflexively shape behaviour and speech. This study used path modelling to consider links from emotion-related and non-emotion-related impulsivity to a broad range of psychopathologies.

DESIGN AND METHODS

Undergraduates completed self-report measures of impulsivity, depression, anxiety, aggression, and substance use symptoms.

RESULTS

A path model (N = 261) indicated specificity of these forms of impulsivity. Pervasive Influence of Feelings was related to anxiety and depression, whereas Feelings Trigger Action and non-emotion-related impulsivity were related to aggression and substance use.

CONCLUSIONS

The findings of this study suggest that emotion-relevant impulsivity could be a potentially important treatment target for a set of psychopathologies.

PRACTITIONER POINTS

Recent work has differentiated two forms of emotion-related impulsivity. This study tests a multivariate path model linking emotion-related and non-emotion-related impulsivity with multiple forms of psychopathology. Impulsive thoughts in response to negative emotions were related to anxiety and depression. Impulsive actions in response to emotions were related to aggression and substance use, as did non-emotion-related impulsivity. The study was limited by the reliance on self-report measures of impulsivity and psychopathology. There is a need for longitudinal work on how these forms of impulsivity predict the onset and course of psychopathology.

Intertemporal Choice Behavior in Emerging Adults and Adults: Effects of Age Interact with Alcohol Use and Family History Status

Adults with alcohol use disorders (AUDs) show marked immediate reward selection (or "Now") bias in intertemporal choice tasks. This Now bias persists long into abstinence, suggesting an irreversible consequence of chronic alcohol abuse or a pre-existing AUD intermediate phenotype. However, some data show substantial Now bias among emerging adults (18-25), regardless of drinking behavior, suggesting age-dependent effects on Now bias. The objectives of the present study were to determine (1) whether Now bias is greater among emerging adults relative to adults, (2) whether any such age effect on Now bias is diminished in sub-clinical heavy alcohol users, and (3) whether having a problem drinking first degree relative is independently associated with elevated Now bias. To achieve these objectives, we used an intertemporal choice task to quantify Now bias in n = 237 healthy participants (ages 18-40; 50% female), and a wide range of non-zero alcohol use, based on the Alcohol Use Disorders Identification Test (AUDIT). We found that among non-heavy drinkers, Now bias inversely correlated with age; this relationship was not present among heavy drinkers. We found no significant relationship between AUDIT score and Now bias among emerging adults, but AUDIT scores and Now bias were positively correlated among 26-40 year olds. Additionally, non-heavy drinking adults who reported a problem drinking first degree relative showed greater Now bias compared to those not reporting familial problem drinking. While not definitive, these findings lend support for elevated Now bias in adulthood as an intermediate phenotype for AUDs. Moreover, non-additive effects of age and heavy drinking on Now bias suggest perturbations in largely common neural circuits in both groups.

Episodic heavy drinking, problem drinking and injuries - results of the WHO/NIAAA collaborative emergency room study in South Korea

Alcohol is the 5th leading risk factor to the global disease burden and disability and about half of the global alcohol burden was attributable to injuries. Despite a large body of evidence documenting the associations between alcohol and injuries, data from Asian countries including South Korea are sparse. The aim of this study was to investigate the associations between episodic heavy past-year drinking, problem drinking symptomatic of alcohol dependence and alcohol-related and intentional injuries. Data from 1989 injured patients recruited for the WHO/NIAAA Collaborative Study on Alcohol and Injury in South Korea were analyzed with respect to the prevalence rates and associations between injuries and frequency of past-year episodic heavy drinking and problem drinking. In estimating the odds ratios (ORs) and the associated 95% confidence intervals between alcohol intake and injuries multivariable logistic models were employed to adjust for sociodemographic characteristics and selected drinking variables. All analyses were conducted using the SAS 9.2 software. Findings of this study were consistent with prior studies that the risk of alcohol-related or intentional injury was positively associated with the frequency of episodic heavy drinking. The magnitudes of the associations were larger with frequent consumption of 5+ drinks (OR=4.0 approximately) than with frequent consumption of 12+ drinks (OR=3.1). Strong associations were also noted between RAPS4-assessed alcohol dependence and alcohol-related and intentional injuries. Further, the prevalence of intentional injury and its association with alcohol increased sharply once the acute alcohol intake exceeded 90 ml. Our results were consistent with prior studies that episodic heavy consumption, acute intoxication and problem drinking are pervasive among emergency room patients. Results of our study also lent support for administering a single-item screener querying consumption of 5+ drinks at a sitting in the past 12 months as a triage tool in Korea.

The role of alcohol consumption in female victimization: findings from a French representative sample

Alcohol is frequently related to interpersonal aggression, but information regarding the role of alcohol consumption by victims of severe aggression is however lacking. In order to better understand the dynamic of victimization, we investigated contextual, facilitator, and psychological impact variables related to victimization in a French sample composed of 1,033 females aged 18-74 years. The participants were recruited using quota sampling methodology, and responses were measured using Computer-Assisted Self-Interviewer. A logistic regression was conducted using a backward elimination procedure to identify the significant predictors of blows and wounds suffered in the past 24 months. The results indicated that victims, relative to nonvictims, did binge drink significantly more often, had a higher aggression trait, and had experienced more social hardships in the past. The study's limitations are noted.

Alcohol and drug use among patients presenting to an inner-city emergency department: a latent class analysis

The inner city Emergency Department (ED) provides a window of opportunity for screening for alcohol and other drug misuse and substance use disorders (SUDs), in order to facilitate linkage for individuals who are in need of services targeting such issues. The majority of prior work in this area has focused on alcohol use. This study used latent class analyses to characterize substance use/SUDs among adults presenting to the ED for medical complaints or injuries. Participants (n=14,557; 77% participation; 45% male; 54% African-American) completed a computerized survey assessing demographics, health functioning, and substance use/SUDs. Although injured patients were significantly more likely to use tobacco, alcohol, and marijuana, and were more likely to have an alcohol use disorder, presenting complaint was not related to other drug use/diagnoses. Five latent classes were identified: (1) low users/SUDs (65.9%) (2) binge drinkers (24.3%), (3) marijuana users/SUD (3.5%), (4) cocaine users/SUD (2.9%), and (5) poly-drug users (3.3%). Compared to class 1, participants in the other classes were younger, male, without health insurance, with poor mental health functioning, tobacco users, and had prior substance use treatment. African-Americans were most likely to be in classes 3 or 4 and employed participants were most likely to be in class 2. In comparison to class 1, classes 2 and 3 reported better physical health; class 2 was more likely to present for injury whereas class 5 was more likely to present for a medical complaint. ED-based screening and interventions approaches need to address the co-occurrence of alcohol, illicit drug, and psychoactive prescription drug use.

Problematic alcohol use and HIV risk among Black men who have sex with men in Massachusetts

This analysis was designed to explore the frequency of problem drinking and its role in potentiating HIV risk among a community-recruited sample of Black men who have sex with men (MSM) in Massachusetts. Black MSM (n=197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered survey, including HIV sexual behavior, the Center for Epidemiologic Studies Depression Scale (CES-D), and the CAGE alcohol screener. Bivariate and multivariable logistic regression procedures examined the association of behavioral HIV-risk factors and other psychosocial variables with problematic alcohol use (CAGE score 3 or 4). Overall, 29% of the sample was found to abuse alcohol. In a multivariable model adjusting for demographic and behavioral variables, factors associated with increased odds of problem drinking were: (1) depressive symptoms (CES-D 16); (2) one or more episodes of serodiscordant unprotected anal sex during last sexual encounter with a casual male partner; and (3) one or more episodes of unprotected anal or vaginal sex with a female partner in the past 12 months. Black MSM who engaged in HIV risk behaviors may be more likely to have concurrent problematic alcohol use. HIV prevention interventions with Black MSM may benefit from incorporating screening and/or treatment for alcohol problems, as well as screening for co-morbid depressive symptoms.

Screening for alcohol problems among 4-year colleges and universities

OBJECTIVE

To assess the use of alcohol screening tools across US colleges.

PARTICIPANTS

Directors of health services at 333 four-year colleges.

METHODS

An online survey was conducted regarding the use of alcohol screening tools. Schools reporting use of formal tools were further described in terms of 4 tools (AUDIT, CUGE, CAPS, and RAPS) that the authors judged to be the most favorable based on prior empirical comparative studies.

RESULTS

Forty-four percent of colleges reported use of at least 1 formal alcohol screening tool and nearly all of these used a tool appropriate for college students. However, less than half of the 44% of colleges that used a screening tool used 1 of the 4 most favorable tools.

CONCLUSIONS

Continued efforts are needed to encourage colleges to use the most effective available screening tools to identify alcohol-related problems that require intervention among students.

ALCOHOL AND VIOLENCE-RELATED INJURIES AMONG EMERGENCY ROOM PATIENTS IN AN INTERNATIONAL PERSPECTIVE

While alcohol has been found to be more closely associated with violence-related injury than with injury from other causes, little data is available which documents heterogeneity in this association across countries or cultures, taking into consideration usual drinking patterns and other socio-cultural variables. Data are reported from 15 countries comprising the Emergency Room Collaborative Alcohol Analysis Project and the WHO Collaborative Study on Alcohol and Injury. Case-crossover analysis was used to analyze the risk of injury (among current drinkers) from drinking six hours prior to the event, based on frequency of usual drinking, for violence-related injuries and separately for non-violence related injuries. Relative risk (RR) for a violence-related injury was significantly greater than for injuries from other causes across all countries (pooled RR=22.22 vs. 4.33), but the magnitude of risk varied considerably (ranging from 4.68 in Spain to 942 in Canada). Pooled effect size was found to be heterogeneous across countries, and was explained, in part, by the level of detrimental drinking pattern in a country. Risk for a violence-related injury was not significantly different by age (<30 and 30+), reporting 5 or more drinks on at least one occasion during the last year, or reporting symptoms of alcohol dependence. A number of methodological concerns suggest that risk of a violence-related injury compared to injuries from other causes may be inflated, and such variables as context of drinking should be taken into consideration in establishing relative risk and alcohol attributable fraction of violence-related injury across countries and cultures.

Factors associated with substance use problem among Maryland Medicaid enrollees affected by serious mental illness

The objective of this study was to identify long-term factors associated with substance use problem among individuals affected by severe mental illness. Prospective data come from the 1994, 1998, and 2000 waves of the Maryland Mental Health Outcomes Survey conducted among a sub-cohort of adult Medicaid recipients affected by serious mental illness. We estimated factors associated with alcohol and drug problem, as well as a hierarchy of substance use problem severity constructed from the alcohol and drug problem outcomes. Drug problem was the strongest factor associated with alcohol problem, and vice versa. Conceptualizing alcohol and drug problem separately, and as a hierarchy of severity, revealed distinct profiles of significant factors. Further research is warranted to explore the utility of modeling substance use problem in terms of a hierarchy of severity.

Clinically significant depressive symptoms as a risk factor for HIV infection among black MSM in Massachusetts

High rates of depression have been observed among men who have sex with men (MSM) relative to the general adult male population; however, a dearth of research has explored depression among Black MSM. Black MSM (n = 197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered quantitative assessment and voluntary HIV counseling and testing. Bivariate and multivariable logistic regression procedures examined the associations of demographics, behavioral HIV risk factors, and psychosocial variables with depressive symptoms by severity, using the 20-item Center for Epidemiologic Studies Depression Scale (CES-D). Adjusting for demographic and behavioral variables, significant factors associated with (1) clinically significant depressive symptoms (33%; CES-D score > or = 16): being publicly insured by Medicaid, having serodiscordant anal sex with a casual male partner, and being diagnosed with an STD in the prior 12 months; (2) moderate depressive symptoms (19%; CES-D score 16-26): having serodiscordant unprotected anal sex with a casual male partner and being diagnosed with an STD in the prior 12 months; (3) severe depressive symptoms (14%; CES-D score 27+): being publicly insured by Medicaid and reporting difficulty accessing healthcare in the past 12 months. Moderately depressed Black MSM may be more likely to engage in behaviors that place them at increased risk for HIV and other STDs. HIV prevention interventions for Black MSM may benefit from incorporating screening and/or treatment for depression, allowing MSM who are depressed to respond more effectively to behavioral change approaches.

Prevalence and identification of alcohol use disorders among severe mental illness inpatients in Taiwan

AIMS

A higher prevalence of alcohol use disorders (AUD) among psychiatric patients has been reported previously and the identification rate is relatively low. This study was designed to investigate the prevalence and identification of AUD among acute psychiatric inpatients with severe mental illness in a psychiatric hospital in Taiwan.

METHODS

In a two-phase case identification strategy, the Alcohol Use Disorders Identification Test (AUDIT) was used as the first phase screening tool and the Structured Clinical Interview for DSM-IV-TR as the second phase diagnostic interview. The definition of identification was diagnosis of AUD on medical record at discharge.

RESULTS

Of 400 respondents, 42 screened positive and 358 screened negative. All screen-positive respondents and 35 screen-negative respondents entered the second phase interview. The weighted lifetime prevalence of alcohol dependence was 8.3% (95% confidence interval [CI]: 4.6-11.9%); alcohol abuse, 1.5% (95%CI: 0.2-2.8%); and AUD, 9.8% (95%CI: 5.7-13.8%). The overall identification rate of AUD by medical staff was 28.2% (0% for alcohol abuse and 33.3% for alcohol dependence). Patients with mood disorders were prone to being undetected as having AUD.

CONCLUSION

AUD comorbidity was common among inpatients with severe mental illness in Taiwan and was easily neglected by medical staff. It is necessary to use a validated screening questionnaire, such as AUDIT, to detect high-risk patients and then give appropriate interventions to enhance treatment outcome.

Effectiveness of the AUDIT-C as a screening test for alcohol misuse in three race/ethnic groups

BACKGROUND

The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is a brief validated screen for risky drinking and alcohol abuse and dependence (alcohol misuse). However, the AUDIT-C was validated in predominantly White populations, and its performance in different racial/ethnic groups is unclear.

OBJECTIVE

To evaluate the validity of the AUDIT-C among primary care patients from the predominant racial/ethnic subgroups within the United States: White, African American, and Hispanic.

DESIGN

Cross-sectional interview validation study.

PARTICIPANTS

1,292 outpatients from an academic family practice clinic in Texas (90% of randomly sampled eligible).

MEASUREMENTS AND MAIN RESULTS

Race/ethnicity was self-reported. Areas under the receiver operating curve (AuROCs) evaluated overall AUDIT-C performance in the 3 racial/ethnic groups compared to diagnostic interviews for alcohol misuse. AUDIT-C sensitivities and specificities at recommended screening thresholds were compared across racial/ethnic groups. AuROCs were greater than 0.85 in all 3 groups, with no significant differences across racial/ethnic groups in men (P = .43) or women (P = .12). At previously recommended cut points, there were statistically significant differences by race in AUDIT-C sensitivities but not specificities. In women, the sensitivity was higher in Hispanic (85%) than in African-American (67%; P = .03) or White (70%; P = .04) women. In men, the sensitivity was higher in White (95%) than in African-American men (76%; P = .01), with no significant difference from Hispanic men (85%; P = .11).

CONCLUSIONS

The overall performance of the AUDIT-C was excellent in all 3 racial/ethnic groups as reflected by high AuROCs. At recommended cut points, there were significant differences in the AUDIT-C's sensitivity but not in specificity across the 3 racial/ethnic groups.

The alcohol use disorders identification test: an update of research findings

BACKGROUND

The Alcohol Use Disorders Identification Test (AUDIT) has been extensively researched to determine its capability to accurately and practically screen for alcohol problems.

METHODS

During the 5 years since our previous review of the literature, a large number of additional studies have been published on the AUDIT, abbreviated versions of it, its psychometric properties, and the applicability of the AUDIT for a diverse array of populations. The current article summarizes new findings and integrates them with results of previous research. It also suggests some issues that we believe are particularly in need of further study.

RESULTS

A growing body of research evidence supports the criterion validity of English version of the AUDIT as a screen for alcohol dependence as well as for less severe alcohol problems. Nevertheless, the cut-points for effective detection of hazardous drinking as well as identification of alcohol dependence or harmful use in women need to be lowered from the originally recommended value of 8 points. The AUDIT-C, the most popular short version of the AUDIT consisting solely of its 3 consumption items, is approximately equal in accuracy to the full AUDIT. Psychometric properties of the AUDIT, such as test-retest reliability and internal consistency, are quite favorable. Continued research is urged to establish the psychometric properties of non-English versions of the AUDIT, use of the AUDIT with adolescents and with older adults, and selective inclusion of alcohol biomarkers with the AUDIT in some instances.

CONCLUSIONS

Research continues to support use of the AUDIT as a means of screening for the spectrum of alcohol use disorders in various settings and with diverse populations.

Do individuals with a severe mental illness experience greater alcohol and drug-related problems? A test of the supersensitivity hypothesis

The supersensitivity hypothesis posits that individuals with a severe mental illness (i.e., schizophrenia and bipolar disorder; SMI) are more likely to be diagnosed with a substance abuse as opposed to a substance dependence diagnosis, and experience greater negative consequences associated with substance use at lower levels of consumption, as compared with non-SMI substance abusers. This is the first known study to test this hypothesis with a control group of non-SMI substance abusing individuals. Forty-two individuals with only a substance use disorder (SUD-only) and 53 dually diagnosed individuals (DD) were compared on measures of substance use, alcohol and drug dependence, negative consequences, substance use outcome expectancies, and motivation for change. A third group of SMI-only individuals (i.e., no SUD; n=35) were also recruited and all three groups were compared on psychological symptoms. Substance use, negative consequences, substance use outcome expectancies, motivation for change, and severity of alcohol and drug dependence were not found to differ significantly between the DD and SUD-only groups. However, the DD group had significantly greater levels of psychological symptoms, as compared with the SMI-only and SUD-only groups. Overall, this study does not provide support for the supersensitivity hypothesis.

Endogenous opioid blockade and impulsive responding in alcoholics and healthy controls

The opioid receptor antagonist naltrexone (NTX) is one of few approved treatments for alcoholism, yet the mechanism by which it reduces drinking remains unclear. In rats, NTX reduces morphine-induced impulsive choice bias; however, nothing is known about the drug's effect on discrete aspects of impulsive behavior in humans, such as decision-making and inhibitory control. Here, we used a modified delay discounting procedure to investigate whether NTX improves decision-making or inhibitory control in humans. We measured the effect of acute NTX (50 mg) on choice between smaller sooner (SS) and larger later monetary rewards and on response errors (motor mismatch) in a high conflict condition in a group of abstinent alcoholics (AA) and healthy control subjects (CS). We previously reported that AA selected the SS option significantly more often than did CS in this paradigm. If the choice bias of AA is due to enhanced endogenous opioid signaling in response to potential reward, NTX should reduce such bias in the AA group. We found that NTX did not reliably reduce impulsive choice in the AA group; however, NTX's effect on choice bias across individuals was robustly predictable. NTX's effect on choice bias was significantly correlated with scores on Rotter's Locus of Control (LOC) scale; increasingly internal LOC scores predicted increasing likelihood of impulsive choices on NTX. In addition, we found that NTX significantly enhanced control of motor responses, particularly within the CS group. These results suggest that endogenous opioids may impair response selection during decision-making under conflict, and that NTX's effects on explicit decision-making are personality-dependent. Determining the biological basis of this dependence could have important implications for effective alcoholism treatment.

The Michigan Alcoholism Screening Test and its shortened form: a meta-analytic inquiry into score reliability

Meta-analytic methods provide a framework around which an inquiry into MAST and SMAST score reliability was completed. Of the 470 measurement opportunities observed between 1971 and 2005, 62 (13.2%) were coupled with accurate reliability information. Weighted reliability estimates centered on .80 suggesting that the MAST and SMAST generally produce scores of similar and adequate reliability for most research purposes. However, the variability of internal consistency estimates shows that at times these tools will not produce reliable scores, particularly among female and nonclinical respondents. Multiple regression equations provide practical guidelines to improve reliability estimates for the future use of these instruments.

Impulsive responding in alcoholics

BACKGROUND

Impaired decision-making is one diagnostic characteristic of alcoholism. Quantifying decision-making with rapid and robust laboratory-based measures is thus desirable for the testing of novel treatments for alcoholism. Previous research has demonstrated the utility of delay discounting (DD) tasks for quantifying differences in decision-making in substance abusers and normal controls. In DD paradigms subjects choose between a small, immediate reward and a larger, delayed reward.

METHODS

We used a novel computerized DD task to demonstrate that abstinent alcoholics (AA, n=14) choose the larger, delayed option significantly less often than control subjects (n=14; p<0.02). This difference in choice tendency was independent of subject age, gender, years of education, or socio-economic status.

RESULTS

All subjects discounted as a function of reward delay and amount, with alcoholics demonstrating steeper discounting curves for both variables. This tendency to discount delayed rewards was positively correlated with subjective reports of both alcohol addiction severity (Drug Use Screening Inventory-Revised, Domain 1, p<0.01), and impulsivity (Barratt Impulsivity Scale-11, p<0.004). Novel aspects of this new paradigm include an element of time pressure, an additional experimental condition that evaluated motor impulsivity by assessing the ability to inhibit a pre-potent response, and another control condition to requiring non-subjective choice.

CONCLUSIONS

Non-alcoholic controls and alcoholics did not differ on motor impulsivity or non-subjective choice, suggesting that the differing choice behavior of the two groups was due mainly to differences in cognitive impulsivity.

Clinical assessment compared with breathalyser readings in the emergency room: concordance of ICD-10 Y90 and Y91 codes

OBJECTIVES

The purpose of this study was to analyse the validity of clinical assessment of alcohol intoxication (ICD-10 Y91) compared with estimated blood alcohol concentration (BAC) using a breath analyser (ICD-10 Y90) among patients in the emergency room (ER).

METHODS

Representative samples of ER patients reporting within six hours of injury (n = 4798) from 12 countries comprising the WHO Collaborative Study on Alcohol and Injuries were breath analysed and assessed blindly for alcohol intoxication at the time of ER admission. Data were analysed using Kendall's Tau-B to measure concordance of clinical assessment and BAC, and meta analysis to determine heterogeneity of effect size.

RESULTS

Raw agreement between the two measures was 86% (Tau-B 0.68), but was lower among those reporting drinking in the six hours prior to injury (raw agreement 39%; Tau-B 0.32). No difference was found by gender or for timing of clinical assessment in relation to breath analysis. Patients positive for tolerance or dependence were more likely to be assessed as intoxicated at low levels of BAC. Estimates were homogeneous across countries only for females and for those negative for alcohol dependence.

CONCLUSIONS

Clinical assessment is moderately concordant with level of BAC, but in those patients who have actually been drinking within the last six hours the concordance was much less, possibly because, in part, of a tendency on the part of clinicians to assign some level of intoxication to anyone who appeared to have been drinking.

Screening for alcohol problems in two emergency service samples in Poland: comparison of the RAPS4, CAGE and AUDIT

Prior research on alcohol-related problems among emergency service patients in Poland found substantial alcohol involvement on the part of injured males, suggesting emergency services may be a productive venue for identifying patients who could benefit from a brief intervention or referral for treatment. Performance of the RAPS4, CAGE and AUDIT against ICD-10 and DSM-IV criteria for alcohol dependence and for alcohol abuse/harmful drinking was compared in probability samples of emergency service patients from two regions of Poland. Sensitivity of the RAPS4 and AUDIT was significantly better than the CAGE for alcohol dependence among males in Warsaw, but specificity was poorer. Among females, although numbers were small, sensitivity for alcohol abuse/harmful drinking and for alcohol dependence or abuse/harmful drinking was significantly better for the RAPS4-QF than for the CAGE or AUDIT at a cut point of 8 across both sites. Performance of the AUDIT at a cut point of 3 was similar to the RAPS4-QF for females. Among males, sensitivity was higher but specificity considerably lower for the RAPS4-QF compared to the CAGE at a cut point of 1 or for the AUDIT at a cut point of 8. Alternate cut points for the AUDIT optimized performance. Findings suggest some regional and gender differences in performance of screening instruments in these Polish samples, but no instrument or cut point is optimal in identifying those with alcohol use disorders. Additional cross-cultural research is needed to evaluate the performance of instruments, especially among females with alcohol use disorders.

Alcohol screening in young persons attending a sexually transmitted disease clinic. Comparison of AUDIT, CRAFFT, and CAGE instruments

OBJECTIVE

To compare the ability of 3 brief alcohol screens (Alcohol Use Disorders Identification Test [AUDIT], CRAFFT, and CAGE) to identify adolescents and young adults with a current alcohol use disorder (AUD) and to determine whether there are gender-based or race-based differences in screening performance.

DESIGN, PARTICIPANTS, AND SETTING

Cross-sectional study of 358 young persons (55% males; 49% blacks; age range, 15-24 years; mean age, 20.6 years) who were attending an urban clinic for sexually transmitted diseases and reported alcohol use during the past year.

MEASUREMENTS

Receiver operating characteristic (ROC) curve analysis was used to determine the ability of the 3 screens to discriminate between participants with and without AUDs detected in the Structured Clinical Interview for DSM-IV (SCID).

RESULTS

One third (33%) of participants met Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for a current AUD (24% with alcohol abuse and 9% with alcohol dependence). The AUDIT performed best at a cut score of 9 (sensitivity, 0.76; specificity, 0.79), CRAFFT at a cut score of 2 (sensitivity, 0.94; specificity, 0.33), and CAGE at a cut score of 1 (sensitivity, 0.69; specificity, 0.63). The AUDIT had the best overall performance (area under the curve [AUC], 0.84), followed closely by CRAFFT (AUC, 0.79) and then CAGE (AUC, 0.70). Performance of screens did not differ by gender. The AUDIT performed slightly better in whites than blacks, but no race-based differences were observed for the CAGE or CRAFFT.

CONCLUSIONS

Clinicians should use the AUDIT or CRAFFT, rather than the CAGE, to screen young persons for AUDs. The AUDIT performs best, but its length may limit its utility in this setting. The CRAFFT is a suitable alternative, with excellent sensitivity and no gender-based or race-based differences.

Comparison of trauma center patient self-reports and proxy reports on the Alcohol Use Identification Test (AUDIT)

BACKGROUND

There has been increased attention on identifying alcohol problems among individuals admitted to trauma centers. Reports about patients' drinking made by significant others represent one potential method to address both concerns about the validity of patients' self-reports and the need to have a proxy measure for trauma patients who are unable to provide information about their drinking behavior. The present study evaluated the level of agreement between trauma patients' self-report and proxy report on the Alcohol Use Disorders Identification Test (AUDIT).

METHODS

The study consisted of patients admitted to a Level I trauma center who screened positive for potential alcohol problems, who completed the AUDIT and National Institute of Mental Health Diagnostic Interview Schedule (Form III-R), and who had a collateral who provided proxy information about the patient. Proxy informants completed the AUDIT on the basis of their knowledge and perception of patients' drinking behavior, as well as a checklist of alcohol-related problems experienced by the patients in the 30 days before admission.

RESULTS

Patient- and proxy-completed AUDIT total and subscale scores were highly correlated and did not differ from one another except for the dependence subscale, with proxies indicating a higher number of symptoms than did patients. A relatively high percentage of agreement (77.5%) was found overall in the classification of patients as having or not having problem drinking on the basis of self-report and proxy AUDITs; 56.4% of both sources indicated a drinking problem and 21.1% of both agreed that there was not a problem. Patients classified as having problem drinking on self-report AUDITs were rated by proxies as having significantly higher levels of hazardous drinking, alcohol-related problems, and dependence symptoms than patients whose AUDIT classified their drinking as nonproblematic.

CONCLUSION

The relative comparability of proxy- and patient-completed AUDIT scores and classifications suggests that patient and proxy reports corroborate and, in cases of trauma patients' inability to provide self-reports, may serve as proxies for patients' reports of drinking.

An examination of the factor structure of the Alcohol Use Disorders Identification Test in two high-risk samples

The Alcohol Use Disorders Identification Test (AUDIT) was examined by employing confirmatory factor analytic techniques to data from two samples collected 1998-1999: college students (n = 465) and court-referred, substance use treatment outpatients (clinical sample; n = 135). Despite the fact that the AUDIT was originally designed as a three-factor measure (consumption, dependence, and consequences), previous studies have lent support to one- and two-factor models. The results of this study support a two-factor model (alcohol consumption and dependence/consequences) in both samples. As further evidence that the two-factor model is appropriate, a psychometric evaluation suggested that the AUDIT generated reliable scores in both groups when used as either a one- or two-factor measure, but not when three scores are derived in the student sample.

Screening for drug use disorders in the emergency department: performance of the rapid drug problems screen (RDPS)

Little research is available on brief screening instruments for identify those meeting diagnostic criteria for drug dependence or abuse. A brief, four-item screening instrument, called the rapid drug problems screen (RDPS), was developed from a similar instrument for alcohol use disorders, the rapid alcohol problems screen (RAPS). Performance of the RDPS was evaluated against DSM-IV and ICD-10 criteria for drug dependence and for dependence or abuse in a sample of 703 emergency department patients in Mexico City. Among males, sensitivity and specificity were 91 and 96%, respectively, for dependence and 93 and 96%, respectively, for dependence or abuse. Neither of the two females meeting diagnostic criteria for dependence or abuse were identified by the RDPS. Area under the receiver-operating characteristic curve indicates an optimum cut point of 1. The data suggest that the RDPS may hold promise as a brief screening instrument for substance use among males, but should be tested in larger populations of females meeting diagnostic criteria for drug use disorders, and across ethnic subgroups in other geographic locales.

Screening and prevention of alcohol and drug use disorders in women

Today a variety of treatments are available for women with SUDs. They range from psychosocial interventions such as motivational enhancement therapy, cognitive-behavioral therapy, and 12-step recovery to pharmacotherapies such as buprenorphine, methadone, and naltrexone. Although the general public remains skeptical of SUD treatment, national studies consistently find it to be both clinically and economically efficacious. In Oregon, for example, researchers found that every dollar invested in drug treatment saved taxpayers dollars 5.60. By the time a woman walks through the door of a drug treatment program, however, her disorder is likely to be firmly engrained. The medical practitioner's office provides an ideal setting for screening and early identification of high-risk alcohol and other drug use and abuse. A variety of reliable and valid self-report measures are available. Sadly, however, the majority of health providers still do not routinely screen patients for alcohol or drug problems. The consequences can be severe, particularly for women. Although efforts have focused on practitioner education and strategies to address practical barriers to implementation (eg, time, resources), much less attention has focused on the pessimistic views of practitioners about SUDs and treatment efficacy. New strategies are needed to enhance practitioner feelings of self-efficacy about their ability to identify and intervene early in the progression from alcohol use to abuse to dependence.

Characteristics of intoxicated trauma patients

Of 1320 patients who were hospitalized for injuries, a total of 315 were known to be intoxicated with alcohol at the time of trauma. A retrospective chart review was performed to determine which biopsychosocial markers correlated with increasing severity of alcohol use disorders in a sample of 184 (58.4%) of these 315 patients. Markers associated with increased severity were: an increased mean corpuscular volume (MCV; p = 0.007), previous legal problems (p = 0.023), previous alcohol rehabilitation (p < 0.001), previous attendance at self-help meetings (p < 0.001), admitting to having an alcohol problem (p < 0.001), and a willingness to change drinking behavior (p < 0.001). Routine toxicology screening tests, simple questions about previous alcohol or drug abuse treatment, and direct questions about the patient's own perception of the severity of disease and readiness to change drinking behavior can identify many victims of major trauma who could potentially benefit from a referral for alcohol rehabilitation.

Identification and brief treatment of alcohol problems with medical patients: an international perspective

This article summarizes the proceedings of a symposium at the 2002 RSA meeting in San Francisco, California. The chair was Peter Monti and co-chair was Nancy Barnett. The aim of the symposium was to bring together researchers from the United States, Sweden, and Mexico to present current findings on the development and implementation of screening and intervention research in Emergency Departments (ED). Cheryl Cherpitel presented findings on the performance of the Rapid Alcohol Problems Screen (RAPS4), a 4-item instrument used for screening for alcohol dependence and harmful drinking in the ED. Dr. Cherpitel also presented for her collaborator, Guilherme Borges, their research on the performance of a number of screening measures including the RAPS among Mexicans and Mexican-Americans with alcohol-related disorders in the ED. Preben Bendtsen described the implementation of an alcohol screening and intervention procedure delivered by ordinary ED staff in Sweden. Nancy Barnett presented data on characteristics related to readiness to change alcohol use in a sample of young adults who were treated in an ED for injury or intoxication.

Feasibility of screening and intervention for alcohol problems among young adults in the ED

This study evaluates the feasibility of screening and brief intervention (SBI) for alcohol problems among young adults (18-39 years) in a rural, university ED. Research staff screened a convenience sample of patients waiting for medical treatment with the Alcohol Use Disorders Identification Test (AUDIT), used motivational interviewing techniques to counsel screen-positive patients (AUDIT >/= 6) during the ED visit, and referred patients to off-site alcohol treatment as appropriate. Patients were interviewed again at 3 months. Eighty-seven percent of age-eligible drinkers (2,067 of 2,371) consented to participate. Forty-three percent (894 of 2,067) screened positive, of which 94% were counseled. Forty percent of those counseled set a goal to decrease or stop drinking and 4% were referred for further treatment. Median times for obtaining consent, screening, and intervention were 4, 4, and 14 minutes, respectively. Project staff reported that 3% of patients screened or counseled were uncooperative. Seventy percent of 519 patients who participated in follow-up interviews agreed the ED is a good place to help patients with alcohol problems. High rates of informed consent and acceptance of counseling confirmed this protocol's acceptability to patients and indicated patients were comfortable divulging alcohol-related risk behavior. The modest times required for the process enhanced acceptability to patients as well as ED staff. The high prevalence of alcohol problems and the broad acceptance of SBI in this sample provide evidence of the ED's promise as a venue for this clinical preventive service.

The Alcohol Use Disorders Identification Test (AUDIT): a review of recent research

BACKGROUND

Efficient, inexpensive screening for early stage alcohol problems is important in health care settings. The Alcohol Use Disorders Identification Test (AUDIT) has been studied extensively to establish its value in this regard.

METHODS

A literature search that used EtOH as a database was conducted to identify studies published on the AUDIT through September 2001. Keywords used for the search were "Alcohol Use Disorders Identification Test" and "AUDIT." All studies reporting psychometric properties of the measure were reviewed with particular attention being given to the period 1996 and later. A small number of additional references were located by noting their citation in other studies reviewed.

RESULTS

Although more research is needed on non-English versions to establish their psychometric properties, at least in its English edition, the AUDIT demonstrates sensitivities and specificities comparable, and typically superior, to those of other self-report screening measures. Test-retest reliability and internal consistency are also quite favorable. For males, the AUDIT-C, a shortened version of the AUDIT, appears approximately equal in validity to the full scale.

CONCLUSIONS

Recent research continues to support use of the AUDIT as a means of screening for alcohol use disorders in health care settings in the United States.

Screening and brief interventions for alcohol use disorders in managed care settings

This chapter will focus on the identification and treatment of alcohol use disorders in general medical care settings in the context of managed care systems. The chapter will include the best data available on the prevalence of problem drinking, screening procedures, brief intervention ("talk therapy"), and implementation in managed care environments. The clinical protocols presented were designed for primary care clinicians working with patients seeking routine medical care. The protocol was developed for the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Physicians' Guide. The four steps were designed to help clinicians to screen, to conduct a brief assessment, to provide advice and or referral and to establish follow-up procedures.

The alcohol use disorders identification test: an aid to recognition of alcohol problems in primary care patients

BACKGROUND

Misuse of alcohol is associated with a range of medical problems. Fortunately, a simple pencil-and-paper measure, the Alcohol Use Disorders Identification Test, can effectively and efficiently screen for early-stage alcohol abuse as well as provide the physician information that can assist in brief intervention.

OBJECTIVE

The objective of this article is to briefly summarize research published on the Alcohol Use Disorders Identification Test and suggest its potential role in brief intervention in primary care settings.

METHODS

Scientific literature on the Alcohol Use Disorders Identification Test though 2000 was reviewed and synthesized to address issues relevant to use of the test in primary health care settings.

RESULTS

The Alcohol Use Disorders Identification Test is quite sensitive and specific and compares favorably with alternative self-report screens for alcohol problems.

Acceptability of emergency department-based screening and brief intervention for alcohol problems

OBJECTIVES

To adapt screening and brief intervention for alcohol problems (SBI) to a high-volume emergency department (ED) setting and evaluate its acceptability to patients.

METHODS

Patients at a large public-hospital ED were screened with the Alcohol Use Disorders Identification Test (AUDIT). Screen-positive drinkers (AUDIT score >/= 6) were provided brief, on-site counseling and referral as needed. Three months later, project staff blinded to baseline measures reassessed alcohol intake, alcohol-related harm, alcohol dependence symptoms, and readiness to change.

RESULTS

Of 1, 034 patients approached, 78.3% (810) consented to participate (95% CI = 75.5% to 81.2%), and 21.2% (172) screened positive (95% CI = 18.4% to 24.0%). Of 88 patients with complete intervention data, 94.3% (83) accepted an intervention (95% CI = 89.5% to 99.2%), with acceptance rates ranging from 93% to 100% across four alcohol-problem-severity levels (p = 0.7). A majority (59.0%) set goals to decrease or stop drinking (95% CI = 48.4% to 69.6%). The group recontacted (n = 23) experienced statistically significant decreases in alcohol intake, alcohol-related harm, and dependence symptoms, with measures decreasing for 68%, 52%, and 61% of the patients. Readiness to change also showed statistically significant improvement, with scores increasing for 43% of the patients. Moreover, two-thirds of the patients (15/23) reported at follow-up that SBI was a helpful part of their ED visit.

CONCLUSIONS

High rates of consent and acceptance of counseling for alcohol problems by patients across a wide range of problem severity indicate that this protocol was acceptable to at-risk patients in a public-hospital ED. Improvements in alcohol-related outcome measures at follow-up were strong enough to warrant controlled studies of intervention efficacy.

Screening instruments for alcohol problems: a comparison of cut points between Mexican American and Mexican patients in the emergency room

The performance of alcohol use disorder screening instruments (CAGE, BMAST, AUDIT, TWEAK) at various cut points were compared between a Mexican American emergency room (ER) sample (n = 586) and a sample of ER patients in Mexico (n = 1,417) using ICD-10 and DSM-IV criteria for alcohol dependence and harmful drinking/abuse by gender and injury status. Lowering cut points improved instrument performance substantially for females in both samples. Further research is needed to explore instrument performance by gender and level of acculturation.

Gender, injury status and acculturation differences in performance of screening instruments for alcohol problems among US Hispanic emergency department patients

The sensitivity and specificity of several screening instruments including the CAGE, brief MAST, AUDIT, TWEAK, RAPS, and Trauma Scale, were evaluated against both ICD-10 and DSM-IV criteria for alcohol dependence and for harmful drinking and abuse in a probability sample of 586 Hispanic emergency department patients. Screening instruments were not as sensitive for females as for males, for those in the low acculturation group, or for non-dependent drinkers. Acculturation was positively associated with the likelihood of being a current drinker and among current drinkers, was positively associated with alcohol dependence and with harmful drinking or alcohol abuse.

Performance of screening instruments for identifying alcohol dependence in the general population, compared with clinical populations

Screening instruments for problem drinking have been developed in clinical populations, and little is known of their performance in the general population. Sensitivity and specificity of the CAGE and the TWEAK for ICD-10 and/or DSM-IV criteria for alcohol dependence are compared among those sampled from the southern region in the 1995 National Alcohol Survey (n = 776), and from emergency room (ER) (n = 1327) and primary care clinic (n = 767) samples in Jackson, MS. Sensitivity of the CAGE was higher in both the ER (85%) and primary care (82%) samples than in the general population (75%), although differences were not significant, and this held for males and females alike. Sensitivity of the TWEAK was lower in the general population sample (83%) than in the ER sample (89%), but higher than in the primary care sample (75%). In the general population, sensitivity of both screeners was better (although not significantly so) among those making an ER or primary care visit during the last year than among those not doing so, with the largest difference found for the CAGE (85% vs. 65%, respectively). In a merged sample of the three sites, the interaction of site by screening instrument was not a significant predictor of alcohol dependence for either the CAGE or TWEAK. Data suggest that screening instruments may not perform as well in the general population as in some clinical populations, with more variation apparent across groups for some screeners than for others. Although further analysis is necessary to explore this issue further, attention should be given to selection of the best instrument for use in a given population.