RESPONSES TO A DRUG AND ALCOHOL PROBLEM ASSESSMENT FOR PRIMARY CARE BY ETHNICITY

Differences in responses by ethnic group to The Drug Abuse Problem Assessment for Primary Care (DAPA-PC) were examined. The DAPA-PC is a self-administered (via computer), internet-based screening instrument with automatic scoring, patient profile for medical reference, and unique motivational messages. Results indicate differences between blacks and whites on responses to several items in these instruments. Differences in drug use were also found between the two ethnic groups in hair/urine results. The screening criteria for the DAPA-PC instrument appear to work for both the groups in this study. Differences in responses to alcohol and drug screening instruments by ethnic group should be taken into consideration when designing screening instruments for alcohol and/or other drug use and these instruments should be adapted for different ethnic groups, when necessary. The results of this study suggest that the DAPA-PC instrument is a useful alcohol and drug abuse screening instrument for both the blacks and whites in a primary care population.     

Computerized screening of substance abuse problems in a primary care setting: older vs. younger adults

The purpose of the current study was to examine differences in responses of older adults (age 55 and above) and younger adults (ages 18 to 54) to the Drug Abuse Problem Assessment for Primary Care (DAPA-PC), a computerized drug and alcohol abuse screening instrument developed for primary care settings. Data were collected from a diverse population of 327 adults presenting for care at The George Washington University Medical Faculty Associates clinic in downtown Washington, DC. Results indicated that rates of drug and alcohol abuse were similar in both groups. However, older adults were less likely than younger adults to perceive their drug use as problematic. This finding has serious implications for older adults, who tend to be underrepresented in treatment programs. There is a need for screening seniors and identifying those who may be at risk for substance abuse problems. Differences in responses to alcohol and drug assessments by age should be taken into consideration when designing screening instruments. The results of this study suggest that the DAPA-PC would provide a useful instrument for screening older adults in a primary care setting.     

Computerized Screening of Substance Abuse Problems in a Primary Care Setting: Older vs. Younger Adults

The purpose of the current study was to examine differences in responses of older adults (age 55 and above) and younger adults (ages 18 to 54) to the Drug Abuse Problem Assessment for Primary Care (DAPA‐PC), a computerized drug and alcohol abuse screening instrument developed for primary care settings. Data were collected from a diverse population of 327 adults presenting for care at The George Washington University Medical Faculty Associates clinic in downtown Washington, DC. Results indicated that rates of drug and alcohol abuse were similar in both groups. However, older adults were less likely than younger adults to perceive their drug use as problematic. This finding has serious implications for older adults, who tend to be underrepresented in treatment programs. There is a need for screening seniors and identifying those who may be at risk for substance abuse problems. Differences in responses to alcohol and drug assessments by age should be taken into consideration when designing screening instruments. The results of this study suggest that the DAPA‐PC would provide a useful instrument for screening older adults in a primary care setting.     

Trends in Alcohol-Related Problems among Whites, Blacks, and Hispanics: 1984–1995

The objective of this study was to report trends in alcohol problems among whites, blacks, and Hispanics between 1984 and 1995. Data were obtained from two nationwide probability samples of U.S. households, the first conducted in 1984 and the second in 1995. The 1984 sample consisted of 1777 whites, 1947 blacks, and 1453 Hispanics. The 1995 sample included 1636 whites, 1582 blacks, and 1585 Hispanics. On both occasions, interviews (average length, 1 hr) were conducted in respondents' homes by trained interviewers. The results indicate that between 1984 and 1995, alcohol problems were stable among white and black men and increased among Hispanic men. The rates of three or more alcohol problems for men of each ethnic group for 1984 and 1995 were: 12% and 11% for white men, 16% and 13% for black men, and 9% and 16% for Hispanic men, respectively. Problem prevalence was stable and relatively low among women in all three ethnic groups. Overall, the prevalence of alcohol problems continues to be high among men in the United States. Even though recent research has shown that rates of frequent heavy drinking among white men have declined, we found no corresponding decrease in problem prevalence. Rates of frequent heavy drinking and alcohol-related problems between 1984 and 1995 have remained especially high among black and Hispanic men, suggesting that men of these two ethnic groups should be specifically targeted for renewed prevention efforts.     

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.     

Comparison of Screening Instruments for Alcohol Problems Between Black and White Emergency Room Patients from Two Regions of the Country

A number of brief screening instruments to identify alcohol dependence exist, but the validity of these instruments across ethnic groups or regions of the country is not well established. The sensitivity and specificity of a number of standard screening instruments (CAGE, brief MAST, AUDIT, TWEAK, and RAPS), as well as other measures (History of Trauma Scale, breathalyzer reading, self-reported drinking before the event, and consuming five or more drinks at a sitting at least monthly) are compared against ICD-10 and DSM-IV criteria for alcohol dependence between probability samples of Black and White emergency room patients in Santa Clara County, CA (n= 716) and in Jackson, MS (n= 1330). Variability in the sensitivity of screening instruments among current drinkers was found to be greater between samples for both Blacks and Whites, than for Blacks compared with Whites within the same sample. The AUDIT, TWEAK, and RAPS seemed to perform well by gender and injury status for both Blacks and Whites in the two samples, and no significant differences were found in the performance of these instruments across sample sites. To evaluate the influence of regional differences in alcohol dependence on differences found in the performance of screening instruments, using logistic regression with the simultaneous entry of demographic variables (age, gender, ethnicity, injury status, and site) and drinking variables (breathalyzer reading, serf-reported drinking before the event, and drinking five or more drinks at a sitting at least monthly) to predict alcohol dependence in a merged sample of these patients (Jackson vs. Santa Clara) site was not found to be significant Data suggest that, whereas region of the country may not be important in predicting alcohol dependence in emergency room populations, regional differences in the performance of screening instruments for alcohol dependence may exist, even when ethnicity is taken into account Given distinct regional differences in drinking patterns and problems in the U.S., further research on commonly used screening instruments is needed to determine those screeners most efficient for identifying problem drinking.     

Screening for drug and alcohol abuse among older adults using a modified version of the CAGE.

This study examined the sensitivity, specificity, and receiver operating characteristics (ROC) curves of a modified version of the CAGE, a screening measure used in the detection of older alcohol- and drug-abusing individuals. In a retrospective review of clinical records of 976 patients screened by a geriatric substance abuse program, the authors examined patients' responses on a modified version of the CAGE that included queries regarding drug use. The CAGE was administered to individuals age 50 or over draw from three diagnostic groups: alcohol abuse/dependence, drug abuse/dependence, and normal controls. Analysis of variance and discriminant function analyses revealed that the modified CAGE was able to discriminate both alcohol and drug abusers from controls. Analyses examining test sensitivity, specificity, and ROC curves revealed the CAGE to demonstrate excellent sensitivity but poor specificity. Omitting the "cut down' item from the CAGE significantly improved specificity with only a modest drop in sensitivity. Given the ease of administration and sensitivity to both alcohol and drug abuse, these data suggest that the modified CAGE is well suited as a screening instrument for geriatric drug and alcohol abuse.     

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.     

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.     

Substance use among emergency room patients: an exploratory analysis by ethnicity and acculturation

OBJECTIVE: While substantial literature exists on the role of alcohol in injury occurrence, little is known about other substance use or abuse and injury, or drug use among the alcohol involved at the time of the emergency room (ER) visit. METHOD: A probability sample of 1,429 patients attending the ER at Santa Clara Valley Medical Center (CA) was interviewed and was asked questions pertaining to licit and illicit drug use and alcohol use within 6 hr prior to the event, and drug use within the last year. RESULTS: While drug use within the 6 hr prior to the event was not found to be significantly different between injured and noninjured patients, injured patients were more likely to report drug use during the last year, and those with violence-related injuries were more likely to report drug use during both time periods compared to those with other injuries. Drug use was associated with ethnicity, with whites more likely than blacks or Hispanics to report use. Among Hispanics, acculturation was related to drug use, with those high on acculturation as likely or more likely than whites to report use. Among those reporting alcohol consumption within 6hr prior to the event and those meeting criteria for alcohol dependence, differences across ethnic/acculturation subgroups for drug use in the same 6-hr period were not significant, and a higher prevalence of both 6-hr and 12-month substance use was found compared to those not reporting drinking during the 6 hr and those not alcohol dependent. CONCLUSIONS: Data suggest that ethnic differences in substance use becomes less important among those alcohol involved, and future research should focus on the interaction of alcohol and other substances on injury occurrence. Data also suggest that substance use associated with increasing acculturation among U.S. Hispanics may have a strong impact on health services utilization, and research is needed by gender, ethnicity, and acculturation to determine the burden that substance use places on the ER.     

Alcohol use disorders among emergency department-treated older adolescents: a new brief screen (RUFT-Cut) using the AUDIT, CAGE, CRAFFT, and RAPS-QF

BACKGROUND: Early identification of alcohol use disorders (AUD) among emergency department (ED)-treated patients is important for facilitating intervention and further evaluation outside EDs. A number of brief screening instruments have been developed for identifying patients with AUD, but it is not clear whether they are practical and perform well with older adolescents in an ED setting. This study contrasted four brief screening instruments for detecting DSM-IV-defined AUD and tested a newly developed brief screen for use among ED-treated older adolescents. METHODS: The Alcohol Use Disorders Identification Test (AUDIT), the CAGE, the CRAFFT, and a modified RAPS-QF were given to 93 alcohol-using older adolescents (55% men; aged 18-20 years) in an ED. Receiver operator characteristic analyses were used to evaluate the performance of brief screens against the criterion of a lifetime DSM-IV alcohol abuse or dependence diagnosis. RESULTS: Of existing instruments, the AUDIT had the best overall performance in identifying AUD (sensitivity, 82%; specificity, 78%). A new, shorter screening instrument composed of two AUDIT items, two CRAFFT items, and one CAGE item (RUFT-Cut) performed as well as the AUDIT (sensitivity, 82%; specificity, 78%). CONCLUSIONS: Among existing alcohol screening instruments, the AUDIT performed best for identifying ED-treated older adolescents with alcohol use disorders. The RUFT-Cut is a brief screening instrument for AUD that shows promise for identifying ED-treated older adolescents who are in need of intervention or further evaluation. Future research should focus on use of the RUFT-Cut in other settings with larger, more diverse samples of adolescents.     

Substance use among emergency room patients: an exploratory analysis by ethnicity and acculturation

Objective: While substantial literature exists on the role of alcohol in injury occurrence, little is known about other substance use or abuse and injury, or drug use among the alcohol involved at the time of the emergency room (ER) visit.

Method: A probability sample of 1429 patients attending the ER at Santa Clara Valley Medical Center (CA) was interviewed and was asked questions pertaining to licit and illicit drug use and alcohol use within 6 hr prior to the event, and drug use within the last year.

Results: While drug use within the 6 hr prior to the event was not found to be significantly different between injured and noninjured patients, injured patients were more likely to report drug use during the last year, and those with violence-related injuries were more likely to report drug use during both time periods compared to those with other injuries. Drug use was associated with ethnicity, with whites more likely than blacks or Hispanics to report use. Among Hispanics, acculturation was related to drug use, with those high on acculturation as likely or more likely than whites to report use. Among those reporting alcohol consumption within 6 hr prior to the event and those meeting criteria for alcohol dependence, differences across ethnic/acculturation subgroups for drug use in the same 6-hr period were not significant, and a higher prevalence of both 6-hr and 12-month substance use was found compared to those not reporting drinking during the 6 hr and those not alcohol dependent.

Conclusions: Data suggest that ethnic differences in substance use becomes less important among those alcohol involved, and future research should focus on the interaction of alcohol and other substances on injury occurrence. Data also suggest that substance use associated with increasing acculturation among U.S. Hispanics may have a strong impact on health services utilization, and research is needed by gender, ethnicity, and acculturation to determine the burden that substance use places on the ER.     

DSM-IV, DSM-III-R, and ICD-10 Alcohol and Drug Abuse/Harmful Use and Dependence, United States, 1992: A Nosological Comparison

This study assessed agreement between DSM-IV, DSM-III-R, and ICD-10 diagnoses of alcohol and drug use disorders using data from a large representative sample of the United States population. Agreement between the three diagnostic systems for dependence was good to excellent for past year, prior to the past year, and lifetime diagnoses, for both genders, each ethnic group, and younger and older respondents. Cross-system comparisons between DSM-IV and DSM-III-R abuse were good to excellent, but concordance was consistently poor when ICD-10 harmful use diagnoses were compared with DSM-IV and DSM-III-R abuse diagnoses. Implications of these results are discussed in terms of the degree to which future research findings could be integrated with one another and the results from earlier studies using older versions of the DSM, to advance scientific knowledge in the drug and alcohol fields.     

Reliability and validity of screening instruments for drug and alcohol abuse in adults seeking evaluation for attention-deficit/hyperactivity disorder

A growing number of adults are seeking evaluation for Attention-Deficit/Hyperactivity Disorder (ADHD). Screening for substance use disorders should be included as part of any comprehensive ADHD evaluation. We describe the validity and reliability of the Drug Abuse Screening Test (DAST) and the Alcohol Use Disorders Identification Test (AUDIT) in adults seeking evaluation for ADHD. Internal reliability estimates were excellent for both instruments. Scores on the DAST and AUDIT were higher among patients with a DSM-IV diagnosis of current drug abuse or dependence or current alcohol abuse or dependence, respectively. A cutoff score of 6 or above appears to be optimal for identifying individuals who are current drug abusers. A cutoff score of 6 or above on the AUDIT is suggested for detection of current alcohol abuse in this population. Comparable rates of substance use disorders were observed in ADHD and non-ADHD patients. Both measures are valid and reliable instruments for screening for alcohol and drug abuse among adults seeking evaluation for ADHD.     

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.     

Screening for Alcohol Dependence and Abuse in Women: Description, Validation, and Psychometric Properties of a New Screening Instrument, SWAG, in a Population Study

In this study, we have evaluated the use of a screening instrument in the first phase of a population study of female alcoholism and alcohol problems. The instrument, called SWAG (Screening, Women, and Alcohol in Göteborg), is a 13-item questionnaire. It includes a modified version of CAGE. The study sample consisted of 3,130 women. Of these, a stratified sample of 479 were invited for interview. Validation was done against interview-based clinical diagnosis according to DSM-III-R (alcohol dependence and abuse), with additional use of medical record information. SWAG had similar sensitivity and specificity used on a population sample, as previously has been found for alcohol problem screening instruments tested in clinical settings. Positive predictive value, rarely reported in studies of other alcohol screening instruments, was 40 to 50%. With logistic regression, we developed a promising set of criteria, called SWAG-L, that had similar sensitivity, specificity, and positive predictive value as the longer version SWAG-1, at the same time it consisted of only four items. CAGE had considerably lower sensitivity than SWAG. SWAG can, so far, be recommended for use in epidemiological studies. It may also prove valuable in clinical settings, although that requires a different scoring method. The question, "I have/have had alcohol problems" was the single item that best predicted alcohol dependence and abuse.     

The prevalence of neural tube defects among ethnic groups in Brooklyn,New York

Records of almost 174,000 consecutive births at six Brooklyn hospitals during the years 1968–1976 were reviewed for congenital neural tube defects. Prevalence of anencephaly, myelomeningocele and occipital encephalocele combined was significantly higher in infants delivered to mothers born in Puerto Rico than in offspring of non-Puerto Rican whites or blacks. The association of prevalence rates with ethnicity remained significant after adjustment for several variables. However, when adjustment was made for private or service status the difference between Puerto Ricans and whites, although still appreciable, was no longer statistically significant. No significant differences in prevalence rates between whites and blacks were observed. Sex ratios of affected infants were close to unity in each ethnic group. Statistically significant associations were found between the prevalence of neural tube defects and parity, gravidity and economic status. The patterns of these associations varied among the ethnic groups. A declining trend in the prevalence of myelomeningocele was observed for all ethnic groups.     

The alcohol use disorders identification test (AUDIT) in a college sample.

This study was conducted to estimate the psychometric properties of the questionnaire section of the Alcohol Use Disorders Identification Test (AUDIT) in a college sample using DSM-III criteria for alcohol abuse as the criterion standard. This alcohol screening test was developed for the 10 country AMETHYST project. In this young adult sample the instrument exhibited a sensitivity of .84 and specificity of .71 when utilizing the recommended cut-off score of 11. The 10-item questionnaire section of the AUDIT appears to have important advantages over other alcohol screening instruments such as the CAGE and the MAST.     

Racial identity and its assessment in a sample of African-American men in treatment for cocaine dependence

Substance abuse treatment studies frequently include subjects from different ethnic and racial groups, but many investigations limit the examination of race and ethnicity to the use of nominal labels. This approach reveals little about the social or psychological significance of racial and ethnic group membership to the subjects of study or about the potential effects of these factors on substance-involved behaviors. In this study, a principal components analysis (PCA) with varimax rotation was conducted on the 50-item long form of the Racial Identity Attitude Scale (RIAS) (1) in a sample of 294 African-American men in treatment for cocaine dependence. The RIAS was developed to measure attitudes about race and racial status among blacks, but it has not been utilized widely in substance abuse research. Our findings provide evidence for the structural validity of this instrument in this sample of substance abusers. We discuss how recent advances in racial identity theory and its measurement may provide an important avenue for understanding the psychological consequences of racial group membership and for examining the potential effects of these factors on treatment response in studies of substance misuse.     

Experiences with Hospital Care: Perspectives of Black and Hispanic Patients

BACKGROUND  Significant racial and ethnic differences along several dimensions of patients’experiences with hospital care have been previously documented. However, the relationship between these differences and possible differences in processes of care has not been well described. METHODS  We conducted focus groups with 37 black and Hispanic men and women who had recently been discharged from either medical or obstetrical services at an urban academic medical center to assess which dimensions of these patients’ experiences with care were most important in determining overall levels of satisfaction. RESULTS  Differences were found between Hispanics and blacks in the factors that influence their overall positive and negative experiences. Participants identified two themes that influence experiences with hospital care that are not commonly examined in many patient satisfaction instruments: availability and quality of translators, and attitudes of social workers and nursing staff. CONCLUSIONS  Our findings suggest that hospitals should pursue hiring a culturally diverse work force and should collect racial and ethnically specific data about satisfaction with care including satisfaction with availability of social workers and interpreters.