Ethnic Differences in Performance of Screening Instruments for Identifying Harmful Drinking and Alcohol Dependence in the Emergency Room

This study examines sensitivity and specificity figures associated with screens used to predict harmful drinking and alcohol dependence among current drinkers. The study population comes from a probability sample of emergency room patients in Jackson, MS. Data are presented by gender and injury status (injured versus noninjured) for Blacks and for Whites. The Composite International Diagnostic Interview was used to assess ICD-10 criteria for harmful drinking and alcohol dependence, which were taken as standards. Predictors include screening instruments (CAGE, AUDIT, brief MAST, TWEAK, and History of Trauma Scale), breathalyzer reading, self-reported consumption before the injury or noninjury event, quantity and frequency of drinking, and an abbreviated alcohol dependence experiences measure used in general population surveys. Single items from these screening instruments were also tested as predictors. Overall, the TWEAK and the AUDIT performed best in terms of sensitivity and specificity, but variation across subgroups suggests that the search for a good screening instrument for general use must be continued.     

Contrasting Self-Report Screens for Alcohol Problems: A Review

Current trends in conceptions of alcohol problems and provision of health care put increased emphasis on identifying individuals whose alcohol use and problems cover a range of severity. The purpose of this study is to begin to provide information on the relative utility of self-report measures designed to identify (screen for) individuals with alcohol problems. To achieve this goal, the empirical literature on contrasts of self-report screening measures was reviewed, and 13 relevant studies across diverse settings and subject populations were identified. The review showed that the CAGE, the Michigan Alcoholism Screening Test (MAST), and the short MAST (sMAST) have been the most widely studied self-report instruments to screen for alcohol problems. Direct comparisons show the MAST to be more sensitive than the CAGE, but with elderly patients the CAGE may perform better than the MAST. Furthermore, available data suggest that the CAGE and the sMAST perform comparably. Finally, the CAGE, MAST, and sMAST all perform best when predicting criteria most similar to those the instruments were designed to reflect. The study concludes with a discussion of priorities for research on screening instruments.     

Alcohol in Fatal and Nonfatal Injuries: A Comparison of Coroner and Emergency Room Data from the Same County

Although alcohol is thought to be associated with severity of injury, relatively little data are available that compares alcohol's involvement in injury cases treated in the emergency room (ER) with coroner cases of injury fatality, both coming from the same county. Data from a probability sample of casualty patients 18 years and older treated at the University of Mississippi Medical Center ER in Jackson during a 6-month period ( n = 275) are compared with data from coroner reports of all fatalities from unnatural causes among those 18 and older in the same county during a 1-year period surrounding the 6 months of data collection in the ER ( n = 222). The two samples are compared on demographic characteristics, cause of injury, place of injury, and alcohol use before the event. A significantly larger proportion of the coroner sample was positive for alcohol (57%) and intoxicated (36%), compared with the proportion of those in the ER sample breathalyzed within 6 hr of injury, and reporting no drinking after the event who were positive (15%) and intoxicated (6%). Differences were most pronounced for motor vehicle accidents and fires. Violence-related injuries were more likely in the coroner sample (32%) than in the ER sample (l6%), and they were more likely to involve alcohol at levels of intoxication. Those in the coroner sample were also more likely to be alcohol-positive for injuries occurring in all places except the home of another and the workplace. Using logistic regression, gender (male) and site (coroner) were predictive of a positive blood alcohol across all causes of injury combined. Gender (female), being alcohol-positive and site (coroner) were significantly predictive of motor vehicle accidents. Alcohol was not found to be a significant predictor for falls, other accidents, or injuries resulting from violence. Data suggest that alcohol's association with severity of injury varies by cause of injury.     

Alcohol Consumption in Emergency Room Patients and the General Population: A Population-Based Study

Our purpose was to obtain epidemiological measures of the association between habitual alcohol consumption, alcohol consumption before the event and alcohol abuse/dependence, and emergency room (ER) attendance compared to the general population in Pachuca-Hidalgo, a city located in the central area of Mexico. The study was a population based case-control design. Data consisted of breath samples to estimated blood alcohol concentration, as well as an interviewer-administered questionnaire, collected on a 24-hr basis, during the entire week, in each of the three main ERs of Pa-chuca. Cases were all patients who visited the three main hospitals ERs during the study period, classified according to their status as an injured or noninjured (medically ill) patient ( n = 1511). The general population sample (n = 920) serves as a comparison group for both types of patients. Injured patients in the ER sample were significantly more likely to report high frequency/high quantity of drinking during the last 12 months than the general population [odds ratio and 95% confidence intervals = 5.55 (1.72–17.97)] and to report drinking within 6 hr before the injury. These relationships did not hold for noninjured patients. Both types of patients were more likely to report high frequency of drunkenness during the preceding 12 months, to be positive for alcohol dependence and to report drug use. We found in the city of Pachuca, a large relationship between habitual alcohol consumption and ER injuries. These findings support associations of alcohol consumption and admission to an emergency room found in ER and general population studies in other countries. Due to the increases in the risk found for abuse/dependent in both injured and noninjured patients, they both would benefit with a brief intervention strategy for reducing their alcohol consumption.     

Variations on the CAGE Alcohol Screening Questionnaire: Strengths and Limitations in VA General Medical Patients

Background: Several variations on the CAGE alcohol screening questionnaire have been recommended. This report evaluates modifications and additions to the CAGE. Methods: Alcohol screening questionnaires were evaluated in male VA general medicine patients (n= 227; mean age, 65.8). Mailed questionnaires included two scoring options for the CAGE (standard and last-year time frames), questions about quantity and frequency of drinking, two questions about episodic heavy drinking, and the question “Have you ever had a drinking problem?” Main analyses compared alcohol screening questions, at various cut-points, to a gold standard of hazardous drinking during the past year (≥14 drinks/week or ≥5 drinks on an occasion) and/or DSM-III-R alcohol abuse or dependence, based on standardized interviews. Results: The CAGE questionnaire with a past-year time frame was much less sensitive (0.57 vs. 0.77) but more specific (0.82 vs. 0.59) than the standard CAGE for detecting hazardous drinking during the past year and/or DSM-III-R alcohol abuse or dependence. An eight-item questionnaire that included the standard CAGE was most sensitive (0.92) but had low specificity (0.50). A single question about the frequency of drinking ≥6 drinks on an occasion, included in the eight-item questionnaire, was both relatively sensitive (0.77) and specific (0.83). Conclusion: The CAGE questionnaire with a past-year time frame was an insensitive alcohol-screening test. An eight-item augmented version of the standard CAGE was the most sensitive. A question about the frequency of drinking ≥6 drinks on an occasion performed better than the standard CAGE, which made it the optimal brief screening test for at-risk drinking.     

Relationships between Socioeconomic Status and Drinking Problems among Black and White Men

We sought to examine the relationships between socioeconomic status and drinking problems within the Black and White male populations. A two-way interaction of social class with race/ethnicity, and with drinking consequences and alcohol dependence symptoms was hypothesized among drinkers. Drinking problems were regressed on social class, race/ethnicity, age, alcohol consumption, and drinking settings. Social class was based on a composite of respondent's income, education, and main wage earner's occupation. Two types of drinking problems were analyzed: drinking consequences and alcohol dependence symptoms. Our hypothesis was partially confirmed. Interactions of social class with race/ethnicity and with drinking problems were observed. Less affluent Black men reported greater numbers of drinking consequences and total drinking problems than less affluent White men; the reverse was true for affluent Black and White men. Results suggest that the relationships between socioeconomic status and drinking problems may vary by race/ethnicity.     

A Critical Evaluation of Several Alcohol Screening Instruments Using the CIDI-SAM as a Criterion Measure

Four alcohol screening instruments (the AUDIT, CAGE, MAST, and Svanum's scale) were administered to a sample of 306 undergraduate students at a Midwestern university and were compared with regard to several test characteristics, using the alcohol section of the CIDI-SAM (DSM-IV version) as the criterion measure. The performance of these instruments was evaluated using two subsets of subjects: (1) students who currently met diagnostic criteria for alcohol dependence ( n = 35); and (2) students who met diagnostic criteria for alcohol dependence in the past and/or at present (i.e., lifetime diagnosis; n = 50). The AUDIT performed significantly better than the other three instruments in identifying students who were currently alcohol dependent, providing a moderate degree of clinical utility with this group. The four instruments did not differ significantly in their ability to identify students with a lifetime diagnosis; each measure provided only a modest degree of clinical utility with this group.     

Disparities in Alcohol-Related Problems Among White, Black, and Hispanic Americans

Background: This study assesses racial/ethnic disparities in negative social consequences of drinking and alcohol dependence symptoms among white, black, and Hispanic Americans. We examine whether and how disparities relate to heavy alcohol consumption and pattern, and the extent to which social disadvantage (poverty, unfair treatment, and racial/ethnic stigma) accounts for observed disparities. Methods: We analyzed data from the 2005 U.S. National Alcohol Survey, a nationally representative telephone‐based survey of adults ages 18 and older (N = 6,919). Given large racial/ethnic differences in abstinence rates, core analyses were restricted to current drinkers (N = 4,080). Logistic regression was used to assess disparities in alcohol‐related problems at 3 levels of heavy drinking, measured using a composite variable incorporating frequency of heavy episodic drinking, frequency of drunkenness, and maximum amount consumed in a single day. A mediational approach was used to assess the role of social disadvantage. Results: African American and Hispanic drinkers were significantly more likely than white drinkers to report social consequences of drinking and alcohol dependence symptoms. Even after adjusting for differences in heavy drinking and demographic characteristics, disparities in problems remained. The racial/ethnic gap in alcohol problems was greatest among those reporting little or no heavy drinking, and gradually diminished to nonsignificance at the highest level of heavy drinking. Social disadvantage, particularly in the form of racial/ethnic stigma, appeared to contribute to racial/ethnic differences in problems. Conclusions: These findings suggest that to eliminate racial/ethnic disparities in alcohol‐related problems, public health efforts must do more than reduce heavy drinking. Future research should address the possibility of drink size underestimation, identify the particular types of problems that disproportionately affect racial/ethnic minorities, and investigate social and cultural determinants of such problems.     

Alcohol-Related Problems and Intimate Partner Violence Among White, Black, and Hispanic Couples in the U.S.

OBJECTIVES: This study analyzes gender and ethnic/racial differences in the prevalence of alcohol-related problems among white, black and Hispanic couples in the United States, and assesses their contribution to the risk of intimate partner violence (IPV). METHODS: Our study population consisted of 1440 white, black, and Hispanic couples obtained through a multistage area household probability sample from the 1995 National Alcohol Survey. Alcohol-related problems (i.e., drinking consequences and alcohol dependence symptoms in the last 12 months) were assessed among respondents and their partners. Male-to-female and female-to-male partner violence (MFPV, FMPV) were measured separately using the Conflict Tactics Scale. RESULTS AND CONCLUSIONS: Alcohol-related problems were more prevalent among men than women. Our bivariate analysis demonstrated a significant positive association between male alcohol-related problems and IPV across racial/ethnic groups, and a similar association between female alcohol-related problems and IPV for white and black couples. In the multivariate logistic regression analyses, however, many of these associations were attenuated. After controlling for sociodemographic and psychosocial covariates, male alcohol-related problems were no longer significantly associated with an increased risk of MFPV among white or Hispanic couples. Female alcohol-related problems predicted FMPV, but not MFPV, among white couples. Among black couples, however, male and female alcohol-related problems remained strong predictors of intimate partner violence. SIGNIFICANCE: Alcohol-related problems are important predictors of intimate partner violence, and the exact association between problems and violence seems to be ethnic-specific. Alcohol-related problems, rather than level of alcohol consumption, may be the more relevant factor to consider in the alcohol-partner violence association. Future research is needed to explore the temporal relationships between the development of alcohol-related problems and the occurrence of partner violence.     

Performance of Screening Instruments for Alcohol Problems in the ER: A Comparison of Mexican- Americans and Mexicans in Mexico*

The performance of standard screening instruments and alternate measures against ICD-10 (International Classification of Diseases, 10th revision) and DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th revision) criteria for alcohol dependence and separately for harmful drinking/abuse were compared between probability samples of 1511 emergency room (ER) patients from three hospitals in Pachuca, Mexico, and 586 Mexican-American ER patients in Santa Clara County, California. Sensitivity was highest for the Alcohol Use Disorders Identification Test (AUDIT), TWEAK, and Rapid Alcohol Problems Screen (RAPS) for alcohol dependence; sensitivity was highest for holding five or more drinks for harmful drinking/abuse in both samples. All instruments performed better for alcohol dependence than for abuse/harmful drinking. Arrests for drinking and driving performed better in Santa Clara than in Pachuca, while a positive Breathalyzer reading and reporting drinking prior to the event performed better in Pachuca; both were significantly more sensitive among the injured compared to the noninjured in Pachuca. The data suggest that instrument performance may be similar between those in Pachuca and those in the low acculturation group in Santa Clara, relative to those scoring higher on acculturation. While standard screening instruments appear to work reasonably well in both samples for alcohol dependence, variation across gender, injury, and acculturation subgroups suggests attention should be given to choosing the “best” instrument.     

Injury and the Role of Alcohol: County-Wide Emergency Room Data

The purpose of this study is to describe variables associated with injury in an emergency room (ER) sample that is representative of an entire U.S. county. A probability sample ( n = 3717) of ER patients from the county hospital, 3 of the 0 community hospitals, and the three health maintenance organization hospitals in a single Northern California county were breathalyzed and interviewed at the time of the ER visit. Injured were most likely to consume only 1 or 2 drinks within el hr of injury occurrence. Twenty-three percent reported feeling drunk at the time of the event, and of these, 45% felt the event would not have happened if they had not been drinking. Breathalyzer reading, feeling drunk at the time of the event, and quantity-frequency (Q-F) of usual drinking were found to be predictive of admission to the ER with an injury, whereas breathalyzer reading, Q-F, and being injured in someone's home were predictive of reporting drinking prior to injury. Although feeling drunk at the time of the event and usual drinking patterns are predictive of injury occurrence, drinking prior to the event may not entail large quantities of alcohol consumed, but relatively small amounts consumed in close proximity to the injury event. These alcohol consumption variables may vary, however, depending on the type, cause, and severity of injury.     

Screening Trauma Patients for Alcoholism According to NLAAA Guidelines with Alcohol Use Disorders Identification Test Questions

Drinking pattern criteria (drinking frequency and number of drinks per occasion) issued by the National Institute on Alcohol and Abuse and Alcoholism (NIAAA) to screen primary practice patients for alcohol problems were evaluated in 1216 injured patients treated in a regional trauma center. Vehicular crash victims predominated (50.2%, of whom 64.5% were drivers), followed by victims of violence (31.2%) and nonviolent-injury victims (18.5%). Alcohol Use Disorders Identification Test (AUDIT) questions #1 (drinking frequency) and #2 (drinks/day) were used to assess the patients for current alcohol dependence (CAD). AUDIT responses roughly approximating NIAAA guidelines (high threshold: drinks ≥ 4 times/week, ≥ 5 drinks/day) and those indicating less drinking (low threshold: drinks ≥ 2-3 times/week, ≥3 drinks/day) were chosen. Comparisons were made relative to sensitivity and specificity of responses in detecting CAD. When low threshold responses were used for either question, sensitivity to detect CAD increased overall (#1 from 0.53 to 0.80, #2 from 0.62 to 0.88) as well as among the subgroups of patients, whereas specificity remained high or at acceptable levels overall (#1 from 0.95 to 0.82, #2 from 0.92 to 0.71) and among the subgroups of patients. Study findings suggest that, among injured drivers and other groups of trauma center patients, lesser amounts of drinking should be used as screening criteria for CAD than are used for the general population.     

Screening for alcohol problems in the U.S. general population: comparison of the CAGE,RAPS4, and RAPS4-QF by gender,ethnicity, and service utilization. Rapid Alcohol Problems Screen

BACKGROUND: The purpose of this study was to compare the performance (sensitivity and specificity) of two brief screening instruments, CAGE and the Rapid Alcohol Problems Screen 4 (RAPS4), against ICD-10 and DSM-IV criteria for alcohol dependence and abuse in a representative sample of the U.S. adult household population by gender, ethnicity, and service utilization (emergency room and primary care) in the last year. METHODS: Data are from the Alcohol Research Group's 2000 National Alcohol Survey (n = 7612), which is a computer-assisted telephone interview survey of the U.S. general population 18 and over in all 50 U.S. states and the District of Columbia. RESULTS: Sensitivity of the RAPS4 (0.86) was better than the CAGE (0.67) given similar specificity (0.95 vs. 0.98) and outperformed the CAGE for alcohol dependence across all gender, ethnic, and service utilization groups, except among blacks and Hispanics. The RAPS4 also performed equally well for females and males (0.88 vs. 0.85), whereas sensitivity of the CAGE was lower for females. Although sensitivity of the RAPS4 was better than the CAGE for alcohol abuse, sensitivity was low for both (0.56 and 0.36, respectively). When quantity-frequency (QF) questions (drinking five or more drinks on at least one occasion during the last year and drinking as often as once a month during the last year) were added to the RAPS4, the RAPS4-QF performed significantly better for alcohol abuse and outperformed the CAGE at a cut point of one across all gender, ethnic, and service utilization groups. The RAPS4-QF appeared to be most sensitive for alcohol abuse among both males and females reporting emergency room use (0.90). CONCLUSIONS: The data suggest that the RAPS4 outperforms the CAGE in this general population sample. The addition of a QF question to the RAPS4 improves performance in relation to sensitivity for alcohol abuse, and the RAPS4 and RAPS4-QF may be the instruments of choice in brief screening for alcohol use disorders. Additional research is needed to further explore these issues.     

Detecting Alcohol-Related Problems in Developing Countries: A Comparison of 2 Screening Measures in India

Background: There is inadequate recognition of alcohol misuse as a public health issue in India. Information on screening measures is critical for prevention and early intervention efforts. This study critically evaluated the full and shorter versions of the AUDIT and RAPS4‐QF as screening measures for alcohol use disorders (AUDs) in a community sample of male drinkers in Goa, India. Methods: Data from male drinking respondents in a population study on alcohol use patterns and sexual risk behaviors in randomly selected rural and urban areas of North Goa are reported. Overall, 39% (n = 743) of the 1899 screened men, age 18 to 49, reported consuming alcohol in the last 12 months. These current drinkers were administered the screening measures as part of detailed interviews on drinking patterns and AUD symptoms. Receiver Operating Characteristic (ROC) analysis was conducted for each combination of screening measure and criterion (alcohol dependence or any AUD). Reliability and correlations among the 4 measures were also examined. Results: All 4 measures performed well with area under the curves of at least 0.79. The full screeners that included both drinking patterns and problem items (the AUDIT and the RAP4‐QF) performed better than their shorter versions (the AUDIT‐C and the RAPS4) in detecting AUDs. Performance of the AUDIT and RAPS4‐QF improved with lowered and raised thresholds, respectively, and alternate cut‐off scores are suggested. Scores on the full measures were significantly correlated (0.80). Reliability estimates for the AUDIT measures were higher than those for the RAPS4 measures. Conclusions: All measures were efficient at detecting AUDs. When screening for alcohol‐related problems among males in the general population in India, cut‐off scores for screeners may need to be adjusted. Selecting an appropriate screening measure and cut‐off score necessitates careful consideration of the screening context and resources available to confirm alcohol‐related diagnoses.     

What Triggers the Resolution of Alcohol Problems Without Treatment?*

This study investigated natural recoveries (self-change) from alcohol problems, and overcame several methodological problems that affected the few previous studies of this phenomenon. Three groups of individuals who had resolved an alcohol problem without treatment were interviewed about their drinking history, life events that occurred during the year prior to their resolution, and factors that helped maintain their resolution. As a control for prevalence of life events, a control group of nonresolved, nontreated alcohol abusers were interviewed about events in a randomly selected year. Collaterals were interviewed for all subjects. No life event or constellation of events was differentially associated with the resolutions across the three resolved groups or differentiated the resolved and nonresolved groups. Interviews with resolved subjects were qualitatively analyzed—the majority (57%) of recoveries were characterized as Involving a “cognitive evaluation” or appraisal of the pros and cons of drinking. Spousal support was reported by the greatest number of resolved subjects as having helped them maintain their resolution. Findings from this study may provide direction for developing new treatment strategies and for accelerating self-change among problem drinkers in the community. The study also demonstrates the importance of using a control group, without which very different conclusions might have been drawn.