Screening for Problem Drinking Comparison of CAGE and AUDIT

OBJECTIVE: To compare self-administered versions of three questionnaires for detecting heavy and problem drinking: the CAGE, the Alcohol Use Disorders Identification Test (AUDIT), and an augmented version of the CAGE. DESIGN: Cross-sectional surveys. SETTING: Three Department of Veterans Affairs general medical clinics. PATIENTS: Random sample of consenting male outpatients who consumed at least 5 drinks over the past year ("drinkers"). Heavy drinkers were oversampled. MEASUREMENTS: An augmented version of the CAGE was included in a questionnaire mailed to all patients. The AUDIT was subsequently mailed to "drinkers." Comparison standards, based on the tri-level World Health Organization alcohol consumption interview and the Diagnostic Interview Schedule, included heavy drinking (>14 drinks per week typically or >/=5 drinks per day at least monthly) and active DSM-IIIR alcohol abuse or dependence (positive diagnosis and at least one alcohol-related symptom in the past year). Areas under receiver operating characteristic curves (AUROCs) were used to compare screening questionnaires. MAIN RESULTS: Of 393 eligible patients, 261 (66%) returned the AUDIT and completed interviews. For detection of active alcohol abuse or dependence, the CAGE augmented with three more questions (AUROC 0.871) performed better than either the CAGE alone or AUDIT (AUROCs 0.820 and 0.777, respectively). For identification of heavy-drinking patients, however, the AUDIT performed best (AUROC 0.870). To identify both heavy drinking and active alcohol abuse or dependence, the augmented CAGE and AUDIT both performed well, but the AUDIT was superior (AUROC 0.861). CONCLUSIONS: For identification of patients with heavy drinking or active alcohol abuse or dependence, the self-administered AUDIT was superior to the CAGE in this population.     

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.     

AUDIT-C as a brief screen for alcohol misuse in primary care

BACKGROUND: The Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questions have been previously validated as a 3-item screen for alcohol misuse and implemented nationwide in Veterans Affairs (VA) outpatient clinics. However, the AUDIT-C's validity and optimal screening threshold(s) in other clinical populations are unknown. METHODS: This cross-sectional validation study compared screening questionnaires with standardized interviews in 392 male and 927 female adult outpatients at an academic family practice clinic from 1993 to 1994. The AUDIT-C, full AUDIT, self-reported risky drinking, AUDIT question #3, and an augmented CAGE questionnaire were compared with an interview primary reference standard of alcohol misuse, defined as a Diagnostic and Statistical Manual, 4th ed. alcohol use disorder and/or drinking above recommended limits in the past year. RESULTS: Based on interviews with 92% of eligible patients, 128 (33%) men and 177 (19%) women met the criteria for alcohol misuse. Areas under the receiver operating characteristic curves (AUROCs) for the AUDIT-C were 0.94 (0.91, 0.96) and 0.90 (0.87, 0.93) in men and women, respectively (p=0.04). Based on AUROC curves, the AUDIT-C performed as well as the full AUDIT and significantly better than self-reported risky drinking, AUDIT question #3, or the augmented CAGE questionnaire (p-values <0.001). The AUDIT-C screening thresholds that simultaneously maximized sensitivity and specificity were > or =4 in men (sensitivity 0.86, specificity 0.89) and > or =3 in women (sensitivity 0.73, specificity 0.91). CONCLUSIONS: The AUDIT-C was an effective screening test for alcohol misuse in this primary care sample. Optimal screening thresholds for alcohol misuse among men (> or =4) and women (> or =3) were the same as in previously published VA studies.     

Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population

BACKGROUND: Primary care physicians need a brief alcohol questionnaire that identifies hazardous drinking and alcohol use disorders. The Alcohol Use Disorders Identification Test (AUDIT) questions 1 through 3 (AUDIT-C), and AUDIT question 3 alone are effective alcohol-screening tests in male Veterans Affairs (VA) patients, but have not been validated in women. METHODS: Female VA patients (n = 393) completed self-administered questionnaires, including the 10-item AUDIT and a previously proposed modification to AUDIT question 3 with a sex-specific threshold for binge drinking (>/=4 drinks/occasion), and in-person interviews with the Alcohol Use Disorder and Associated Disabilities Interview Schedule. The AUDIT-C, AUDIT question 3 alone, and the 10-item AUDIT were each evaluated with and without the sex-specific binge question and compared with past-year hazardous drinking (>7 drinks/week or >/=4 drinks/occasion) and/or active Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition alcohol abuse or dependence, based on interviews. RESULTS: Eighty-nine women (22.6%) met interview criteria for past-year hazardous drinking and/or active alcohol abuse or dependence. Standard and sex-specific AUDIT-Cs were sensitive (0.81 and 0.84, respectively) and specific (0.86 and 0.85, respectively). Their areas under the receiver operating characteristic curves were equivalent (0.91, and 0.92, respectively) and slightly higher than for the standard 10-item AUDIT (0.87). A single, sex-specific question about binge drinking (modified AUDIT question 3) had a sensitivity of 0.69 and specificity of 0.94, whereas the standard AUDIT question 3 was specific (0.96) but relatively insensitive (0.45). CONCLUSIONS: The standard and sex-specific AUDIT-Cs are effective screening tests for past-year hazardous drinking and/or active alcohol abuse or dependence in female patients in a VA study.     

The Alcohol Use Disorders Identification Test (AUDIT) as a screening tool for excessive drinking in primary care: reliability and validity of a French version

BACKGROUND: Excessive drinking is a major problem in Western countries. AUDIT (Alcohol Use Disorders Identification Test) is a 10-item questionnaire developed as a transcultural screening tool to detect excessive alcohol consumption and dependence in primary health care settings. OBJECTIVES: The aim of the study is to validate a French version of the Alcohol Use Disorders Identification Test (AUDIT). METHODS: We conducted a validation cross-sectional study in three French-speaking areas (Paris, Geneva and Lausanne). We examined psychometric properties of AUDIT as its internal consistency, and its capacity to correctly diagnose alcohol abuse or dependence as defined by DSM-IV and to detect hazardous drinking (defined as alcohol intake >30 g pure ethanol per day for men and >20 g of pure ethanol per day for women). We calculated sensitivity, specificity, positive and negative predictive values and Receiver Operator Characteristic curves. Finally, we compared the ability of AUDIT to accurately detect "alcohol abuse/dependence" with that of CAGE and MAST. RESULTS: 1207 patients presenting to outpatient clinics (Switzerland, n = 580) or general practitioners' (France, n = 627) successively completed CAGE, MAST and AUDIT self-administered questionnaires, and were independently interviewed by a trained addiction specialist. AUDIT showed a good capacity to discriminate dependent patients (with AUDIT > or =13 for males, sensitivity 70.1%, specificity 95.2%, PPV 85.7%, NPV 94.7% and for females sensitivity 94.7%, specificity 98.2%, PPV 100%, NPV 99.8%); and hazardous drinkers (with AUDIT > or =7, for males sensitivity 83.5%, specificity 79.9%, PPV 55.0%, NPV 82.7% and with AUDIT > or =6 for females, sensitivity 81.2%, specificity 93.7%, PPV 64.0%, NPV 72.0%). AUDIT gives better results than MAST and CAGE for detecting "Alcohol abuse/dependence" as showed on the comparative ROC curves. CONCLUSIONS: The AUDIT questionnaire remains a good screening instrument for French-speaking primary care.     

Brief screening questionnaires to identify problem drinking during pregnancy: a systematic review

Aims Although prenatal screening for problem drinking during pregnancy has been recommended, guidance on screening instruments is lacking. We investigated the sensitivity, specificity and predictive value of brief alcohol screening questionnaires to identify problem drinking in pregnant women. Methods Electronic databases from their inception to June 2008 were searched, as well as reference lists of eligible papers and related review papers. We sought cohort or cross‐sectional studies that compared one or more brief alcohol screening questionnaire(s) with reference criteria obtained using structured interviews to detect ‘at‐risk’ drinking, alcohol abuse or dependency in pregnant women receiving prenatal care. Results Five studies (6724 participants) were included. In total, seven instruments were evaluated: TWEAK (Tolerance, Worried, Eye‐opener, Amnesia, Kut down), T‐ACE [Take (number of drinks), Annoyed, Cut down, Eye‐opener], CAGE (Cut down, Annoyed, Guilt, Eye‐opener], NET (Normal drinker, Eye‐opener, Tolerance), AUDIT (Alcohol Use Disorder Identification Test), AUDIT‐C (AUDIT‐consumption) and SMAST (Short Michigan Alcohol Screening Test). Study quality was generally good, but lack of blinding was a common weakness. For risk drinking sensitivity was highest for T‐ACE (69‐88%), TWEAK (71–91%) and AUDIT‐C (95%), with high specificity (71–89%, 73–83% and 85%, respectively). CAGE and SMAST performed poorly. Sensitivity of AUDIT‐C at score ≥3 was high for past year alcohol dependence (100%) or alcohol use disorder (96%) with moderate specificity (71% each). For life‐time alcohol dependency the AUDIT at score ≥8 performed poorly. Conclusion T‐ACE, TWEAK and AUDIT‐C show promise for screening for risk drinking, and AUDIT‐C may also be useful for identifying alcohol dependency or abuse. However, their performance as stand‐alone tools is uncertain, and further evaluation of questionnaires for prenatal alcohol use is warranted.     

A review of the Alcohol Use Disorders Identification Test (AUDIT), AUDIT-C,and USAUDIT for screening in the United States: Past issues and future directions

Background. The US Preventive Services Task Force recommends that clinicians screen all adults for alcohol misuse and provide brief counseling to those engaged in risky or hazardous drinking. The World Health Organization's (WHO's) Alcohol Use Disorders Identification Test (AUDIT) is the most widely tested instrument for screening in primary health care. Objectives. This paper describes the structural and functional features of the AUDIT and methodological problems with the validation of the alcohol consumption questions (AUDIT-C). The content, scoring, and rationale for a new version of the AUDIT (called the USAUDIT), adapted to US standard drink size and hazardous drinking guidelines, is presented. Method. Narrative review focusing on the consumption elements of the AUDIT. Four studies of the AUDIT-C are reviewed and evaluated. Results. The AUDIT has been used extensively in many countries without making the changes in the first three consumption questions recommended in the AUDIT User’s Manual. As a consequence, the original WHO version is not compatible with US guidelines and AUDIT scores are not comparable with those obtained in countries that have different drink sizes, consumption units, and safe drinking limits. Clinical and Scientific Significance. The USAUDIT has adapted the WHO AUDIT to a 14 g standard drink, and US low-risk drinking guidelines. These changes provide greater accuracy in measuring alcohol consumption than the AUDIT-C.     

Screening with the alcohol use disorders identification test (AUDIT) in an inner-city population

Objectives: 1) To determine the operating characteristics of the Alcohol Use Disorders Identification Test (AUDIT) in an inner-city population and 2) to compare AUDIT performance with physician recognition of alcohol-related problems. Design: New patients were administered a health habits questionnaire, which included the AUDIT and the alcohol portion of the Structured Clinical Interview for DSM-III-R (used as the “gold standard” for alcohol abuse or dependence). The findings were compared with physician recognition based on chart review. Setting: Inner-city general medicine clinic staffed by resident physicians with faculty supervision. Patients/participants: Consecutive new patients over a ten-week period. Of 166 consecutive new patients, 23 were not contacted, 17 refused to participate, two were excluded for gross cognitive deficits, and 124 completed the study. Results: Of the 124 patients, 41 (33%) met criteria for past or present alcohol abuse or dependence. The AUDIT correctly identified 26/27 (sensitivity of 96%) of patients with current problems and 0/14 of patients with past problems only. Physician rates of recognition of current and past alcohol-related problems based on chart review were 12/27 (sensitivity of 44%) and 1/14 (7%), respectively. The specificities of both the AUDIT and physician recognition were high, 96% and 99%, respectively. Conclusions: 1) Alcohol-related problems were common in this setting. 2) The AUDIT had a high sensitivity and a high specificity for detection of current alcohol problems in this setting, but it failed to detect patients with only past histories of alcohol problems. 3) The AUDIT performed significantly better than did the physicians in detecting alcohol problems. 4) The addition of an assessment of past alcohol use to supplement information from the AUDIT would appear to represent a promising screening strategy worthy of further investigation. Presented in part at the annual meeting of the Society of General Internal Medicine, April 30, 1993, Arlington, Virginia. Supported in part by the Alumni Association of Wayne State University Medical School.     

Alcohol screening in young persons attending a sexually transmitted disease clinic

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.     

Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients

Abstract : Background: Primary care providers need practical methods for managing patients who screen positive for at‐risk drinking. We evaluated whether scores on brief alcohol screening questionnaires and patient reports of prior alcohol treatment reflect the severity of recent problems due to drinking. Methods: Veterans Affairs general medicine outpatients who screened positive for at‐risk drinking were mailed questionnaires that included the Alcohol Use Disorders Identification Test (AUDIT) and a question about prior alcohol treatment or participation in Alcoholics Anonymous (“previously treated”). AUDIT questions 4 through 10 were used to measure past‐year problems due to drinking (PYPD). Cross‐sectional analyses compared the prevalence of PYPD and mean Past‐Year AUDIT Symptom Scores (0–28 points) among at‐risk drinkers with varying scores on the CAGE (0–4) and AUDIT‐C (0–12) and varying treatment histories. Results: Of 7861 male at‐risk drinkers who completed questionnaires, 33.9% reported PYPD. AUDIT‐C scores were more strongly associated with Past‐Year AUDIT Symptom Scores than the CAGE (p < 0.0005). The prevalence of PYPD increased from 33% to 46% over the range of positive CAGE scores but from 29% to 77% over the range of positive AUDIT‐C scores. Among subgroups of at‐risk drinkers with the same screening scores, patients who reported prior treatment were more likely than never‐treated at‐risk drinkers to report PYPD and had higher mean Past‐Year AUDIT Symptom Scores (p < 0.0005). We propose a simple method of risk‐stratifying patients using AUDIT‐C scores and alcohol treatment histories. Conclusions: AUDIT‐C scores combined with one question about prior alcohol treatment can help estimate the severity of PYPD among male Veterans Affairs outpatients.     

Do primary care physicians screen patients about alcohol intake using the CAGE questions?

The performances of 134 primary care physicians at initial screening about alcohol use and screening with the CAGE questions were assessed using 17 standardized patients. For three-fourths of the standardized patients, more than 50% of the physicians asked an initial alcohol screening question. However, use of the CAGE questions with six patients who reported drinking more than one drink per day was less consistent; for most of these patients, few physicians asked any CAGE questions. Fewer than 50% of the physicians included alcohol abuse in the differential diagnosis for three of four patients who drank four or more drinks per day. Methods are needed to incorporate the CAGE questions into primary care practices in a more systematic manner. Supported by grant number HS-06454-03 from the Agency for Health Care Policy and Research.     

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.     

An open-label pilot study of icariin for co-morbid bipolar and alcohol use disorder

ABSTRACT

Objectives: Bipolar disorder is associated with a very high prevalence of alcohol-related disorders. However, few studies have examined treatment in this population. Preclinical research suggests a role for the flavonoid icariin in mood and addictive disorders. In this open-label pilot study, we investigated the feasibility and safety of using icariin for persons with bipolar disorder and alcohol abuse or dependence. Methods: Ten participants with bipolar I or bipolar II disorders, currently depressed, and with active alcohol abuse or dependence were given open-label icariin of up to 300 mg/day for 8 weeks using a flexible dosing strategy. Participants were assessed using the Hamilton Rating Scale for Depression (HAMD), Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR), Hamilton Rating Scale for Anxiety (HAMA), and Young Mania Rating Scale (YMRS). Standard drinks, heavy drinking days, and drinking days were also quantified. Baseline and exit data were analyzed using the Wilcoxon Signed Rank Test. Results: We observed a significant decrease in the HAMD (p = 0.012, d = 0.8), QIDS (p = 0.017, d = 0.7), and HAMA (p = 0.005, d = 1.4) scores. Heavy drinking days (p = 0.034, d = 1.1) and standard drinks (p = 0.038, d = 0.8) also decreased significantly. Icariin was well tolerated and no participants withdrew due to side-effects. Conclusion: Results from this uncontrolled study suggest icariin may decrease depressive symptoms and reduce alcohol consumption in persons with bipolar disorder and alcohol use. Improvement in mood and alcohol use was similar to that observed in an open-label trial of naltrexone in this population. Controlled trials, but at this point not routine clinical use, of icariin seem warranted.     

Do Subjective Alcohol Screening Tools Correlate with Biomarkers Among High-Risk Transgender Women and Men Who Have Sex with Men in Lima,Peru?

Alcohol abuse can influence sexual risk behavior; however, its measurement is not straightforward. This study compared self-reported alcohol use, via the AUDIT and CAGE, with levels of phosphatidylethanol (Peth), a phospholipid biomarker that forms with chronic, heavy drinking, among high-risk MSM and TW in Lima, Peru. Chi square, Fisher’s exact, Wilcoxon ranksum tests compared the instruments. Receiver operating curves determined sensitivity and specificity of the self-reported measures. Among 69 MSM and 17 TW, PEth was positive for 86% (95% CI 77–93%) of participants, while 67% reported binge-drinking in the last 2 weeks. The AUDIT classified 25% as hazardous drinkers while CAGE identified 6% as problem drinkers. Self-reported binge drinking was more sensitive than the AUDIT for PEth positivity (71% vs. 27%, p = 0.022). Among high-risk MSM and TW in Lima, validated, self-report measures of alcohol abuse underestimated biological measures. Further research correlating bio-markers and self-reported alcohol abuse measures is needed.     

Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT,POSIT, CAGE,and CRAFFT

BACKGROUND: Adolescents should be screened for alcohol misuse as part of routine care. The objective of this study was to compare the criterion validity of the Alcohol Use Disorders Identification Test (AUDIT), the Problem Oriented Screening Instrument for Teenagers substance use/abuse scale (POSIT), and the CAGE and CRAFFT questions among adolescents. METHODS: Fourteen- to 18-year-old patients arriving for routine healthcare at a large, hospital-based adolescent clinic completed the four screens and the criterion standard Adolescent Diagnostic Interview, which yields DSM-IV diagnoses of alcohol abuse and dependence. Receiver operating characteristic (ROC) curves were plotted to determine optimal cut-points. Areas under the ROC curves of the four screens were compared, and sensitivities and specificities were calculated. RESULTS: Participants' past 12-month alcohol diagnostic classifications were as follows: no use (58.6%), nonproblem use (13.0%), problem use (20.8%), abuse (5.4%), and dependence (2.2%). Optimal cut-points associated with problem use or higher were 2 for AUDIT, 1 for POSIT, 1 for CAGE, and 1 for CRAFFT. ROC curve area of the CAGE was significantly lower compared with areas of all other screens. Sensitivities (95% confidence intervals) were AUDIT 0.88 (0.83-0.93), POSIT 0.84 (0.79-0.90), CAGE 0.37 (0.29-0.44), and CRAFFT 0.92 (0.88-0.96); specificities were AUDIT 0.81 (0.77-0.85), POSIT 0.89 (0.86-0.92), CAGE 0.96 (0.94-0.98), and CRAFFT 0.64 (0.59-0.69). CONCLUSIONS: The AUDIT, POSIT, and CRAFFT have acceptable sensitivity for identifying alcohol problems or disorders in this age group. The CAGE is not recommended for use among adolescents.     

The effects of carbamazepine and lorazepam on single versus multiple previous alcohol withdrawals in an outpatient randomized trial

OBJECTIVE: Benzodiazepines are the mainstay of treatment for mild-to-moderate alcohol withdrawal in outpatient settings, but they can interact with alcohol, cause motor incoordination, or be abused. This study compared the therapeutic responses of the benzodiazepine lorazepam and the anticonvulsant carbamazepine for the outpatient treatment of acute alcohol withdrawal in terms of patients’ previous detoxification histories, and compared the effects of these 2 medications on drinking behaviors in the immediate postdetoxification period. DESIGN: This was a randomized double-blind trial comparing patient responses to carbamazepine and lorazepam across 2 levels of detoxification histories (0–1 or ≥2 previous medicated detoxifications). SETTING: A university medical center substance abuse clinic in Charleston, SC. PATIENTS: One hundred thirty-six patients in moderate alcohol withdrawal were randomized. Major exclusions were significant hepatic or hematologic abnormalities and use of medications that could alter withdrawal symptoms. INTERVENTIONS: Patients received 600–800 mg of carbamazepine or 6–8 mg of lorazepam in divided doses on day 1 tapering to 200 mg of carbamazepine or 2 mg of lorazepam. MAIN OUTCOME MEASURES: The Clinical Institute Withdrawal Assessment for Alcohol-Revised was used to assess alcohol withdrawal symptoms on days 1 through 5 and postmedication at days 7 and 12. Daily drinking was measured by patient report using a daily drinking log and a breath alcohol level with each visit. Side effects were recorded daily. RESULTS: Carbamazepine and lorazepam were equally effective at decreasing the symptoms of alcohol withdrawal. In the post-treatment period, 89 patients drank on at least 1 day; on average, carbamazepine patients drank less than 1 drink per drinking day and lorazepam patients drank almost 3 drinks per drinking day (P=.003). Among those with multiple past detoxifications, the carbamazepine group drank less than 1 drink per day on average and the lorazepam group drank about 5 drinks per day on average (P=.033). Lorazepam-treated patients had a significant rebound of alcohol withdrawal symptoms post-treatment (P=.007) and the risk of having a first drink was 3 times greater (P=.04) than for carbamazepine-treated patients. Twenty percent of lorazepam-treated patients had dizziness, motor incoordination, or ataxia and did not recognize their impairment. Twenty percent of carbamazepine-treated patients reported pruritus but no rash. CONCLUSIONS: Carbamazepine and lorazepam were both effective in decreasing the symptoms of alcohol withdrawal in relatively healthy, middle-aged outpatients. Carbamazepine, however, was superior to lorazepam in preventing rebound withdrawal symptoms and reducing post-treatment drinking, especially for those with a history of multiple treated withdrawals. This research was supported by the National Institutes of Health National Institute on Alcohol Abuse and Alcoholism Center Grant no. AA10761.     

The AUDIT Alcohol Consumption Questions: Reliability, Validity, and Responsiveness to Change in Older Male Primary Care Patients

Objectives : To determine the reliability, validity, and responsiveness to change of AUDIT (Alcohol Use Disorders Identification Test) questions 1 to 3 about alcohol consumption in a primary care setting. Patients : Randomly selected, male general medical patients ( n = 441) from three VA Medical Centers, who had 5 or more drinks containing alcohol in the past year and were willing to be interviewed about their health habits. Measures : Three self-administered AUDIT consumption questions were compared with a telephone-administered version of the trilevel World Health Organization interview about alcohol consumption. Results : Of 393 eligible patients, 264 (67%) completed interviews. Test-retest reliability —Correlations between baseline and repeat measures 3 months later for four dimensions of consumption according to the AUDIT, ranged from 0.65 to 0.85, among patients who indicated they had not changed their drinking (Kendall's Tau-b). Criterion validity —Correlations between AUDIT and interview for four dimensions of alcohol consumption ranged from 0.47 to 0.66 (Kendall's Tau-b). Discriminative validity —The AUDIT questions were specific (90 to 93%), but only moderately sensitive (54 to 79%), for corresponding criteria for heavy drinking. Responsiveness to change —The AUDIT consumption questions had a Guyatt responsiveness statistic of 1.04 for detecting a change of 7 drinks/week, suggesting excellent responsiveness to change. Conclusions : AUDIT questions 1 to 3 demonstrate moderate to good validity, but excellent reliability and responsiveness to change. Although they often underestimate heavy alcohol consumption according to interview, they performed adequately to be used as a proxy measure of consumption in a clinical trial of heavy drinkers in this population.     

Fast alcohol consumption evaluation: a screening instrument adapted for French general practitioners

BACKGROUND: To meet the needs of French general practitioners (GPs), we created a short (5 questions) interview/screening test for alcohol-related problems that is similar to AUDIT in terms of (1) test values and (2) identification of 3 groups: (a) abstainers and low-risk drinkers; (b) heavy drinkers; and (c) alcohol abusers or showing dependence. METHOD: Nine questions (from AUDIT, CAGE, TWEAK, Five-shot Questionnaire) were given systematically to their patients (aged 18 or more) by 41 volunteer GPs. Before the consultation, patients confidentially completed the AUDIT questionnaire in the waiting room. After the consultation, an addiction specialist evaluated each patient's alcohol consumption and DSM-IV criteria for alcohol abuse and dependence and these were used as gold standards. RESULTS: The analysis included 564 patient records and used stepwise logistic regression to select 7 questions, from which a second selection resulted in a 5-item questionnaire. These questions are: AUDIT questions 1 (Frequency) and 2 (Usual quantity), CAGE questions 2 (Annoyed) and 4 (Eye-opener), and TWEAK question 5 (Black-out), with each question scored 0 to 4. High levels of sensitivity and specificity were obtained for each diagnosis (sensitivity 75%-87.8%; specificity 74%-95.8%). CONCLUSION: FACE is an appropriate screening method for French general practitioners.     

Severity of alcohol dependence is negatively related to hypothalamic and prefrontal cortical gray matter density in heavy drinking smokers

Background: While research has examined brain structure in individuals who use alcohol or nicotine, heavy drinking smokers comprise a unique subpopulation of substance users for whom less is known about the relationship between alcohol or nicotine use and structural brain abnormalities. Objectives: The present study examined gray matter morphometry in a sample of 39 heavy drinking smokers (24 males, 15 females) in relation to alcohol and nicotine dependence and quantity of use. Methods: Traditional voxel-based morphometry techniques were employed for preprocessing of imaging data. One multiple regression analysis for alcohol and nicotine dependence severity and another for alcohol and nicotine quantity of use were conducted, while controlling for age, gender, and total intracranial volume (ICV). Results: Alcohol dependence severity was significantly negatively associated with gray matter density in the hypothalamus (p < 0.001, uncorrected) and the right superior frontal gyrus (p < 0.001, uncorrected), while controlling for nicotine dependence severity, age, gender, and ICV. There were no significant relationships observed with respect to nicotine dependence severity, the quantity of alcohol use, or the quantity of nicotine use variables and gray matter density. Conclusions: These findings suggest that within heavy drinking smokers, alcohol dependence severity is significantly related to alterations in brain structure, while this effect is not seen for the quantity of alcohol or nicotine use, or severity of nicotine dependence. The current findings help clarify the contribution of alcohol and nicotine effects on brain structure, which could aid in understanding their neurocognitive consequences in heavy drinking smokers.