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

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

Psychometric properties of alcohol screening tests in the emergency department in Argentina,Mexico and the United States

The objective of this article is to report psychometric characteristics of the AUDIT, CAGE, RAPS4, and TWEAK and to compare them across three countries: Argentina, Mexico, and the United States which used a similar protocol and methodology. Probability samples of patients 18 years and older were drawn from emergency departments in Mar del Plata, Argentina (n = 780), Pachuca, Mexico (n = 1624) and Santa Clara, U.S. (n = 1220). Concurrent validity was assessed by comparing their performance against a diagnosis of alcohol dependence (DSM-IV) obtained through the Composite International Diagnostic Interview, and for the briefer measures, also by their correlation with the AUDIT. The internal consistency of the CAGE, RAPS4, and TWEAK scores was estimated by the KR-20 formula and by Cronbach's Alpha for the AUDIT. Corrected item-total correlation and D-values were used as item discrimination measures.     

The role of alcohol use in emergency department episodes

This study investigates the association between alcohol use and emergency-department (ED) utilization in the United States using nationally representative data from the 2001 National Health Interview Survey (N = 33,326). Estimates from our probit models indicate that among men, current drinkers are less likely to have visited the ED in the past year than former drinkers. Among women, lifetime abstainers are less likely than current drinkers to have had an ED episode. Finally, frequency of binge drinking significantly increases the likelihood of ED visits for men. The results suggest that focusing solely on problem drinking provides a limited perspective.     

Screening for cannabis use disorders in an adolescent emergency department sample

Cannabis, more often than alcohol, is the drug mentioned in substance-related reasons for treatment of an adolescent in an emergency department (ED). This study examined the prevalence of DSM-IV cannabis and alcohol diagnoses in an adolescent ED sample, evaluated the performance (i.e. sensitivity and specificity) of DSM-IV cannabis symptoms and other screening items as indicators of cannabis diagnosis status, and examined parent-adolescent agreement on the presence of cannabis and alcohol diagnoses. Adolescents (ages 13-19, n=442) admitted to an ED for a non-substance-related injury were administered the diagnostic interview schedule for children (DISC). Parents (n=272) of adolescents younger than age 18 completed the DISC-parent version to report on their child's drug use. A minority met criteria for a current DSM-IV cannabis or alcohol diagnosis: 7.9% for both alcohol and cannabis, 7.5% for cannabis-only, and 9.0% for alcohol-only. Frequency of cannabis use had the best overall performance in discriminating those with and without a cannabis diagnosis compared with items on perceived risk of cannabis use, peer cannabis use, and alcohol and cigarette use. Parent reports generally underestimated the adolescent's substance use. Questions on level of substance use generally provide an efficient method of screening adolescents for substance-related problems in an ED setting.     

Effectiveness of screening instruments in detecting substance use disorders among prisoners

This study examined the effectiveness of several screening instruments in detecting substance use disorders among prison inmates. A sample of 400 male inmates were administered eight different substance abuse screening instruments and the Structured Clinical Interview for DSM-IV (SCID-IV), Version 2.0, Substance Abuse Disorders module. The latter was used as a diagnostic criterion measure to determine the presence of substance use disorders. Based on positive predictive value, sensitivity, and overall accuracy, the Texas Christian University Drug Screen, the Simple Screening Instrument, and a combined instrument—Alcohol Dependence Scale/Addiction Severity Index-Drug Use section were found to be the most effective in identifying substance abuse and dependence disorders.     

Screening for stimulant use in adult emergency department seizure patients

OBJECTIVE: The objective of this study was to determine the prevalence of positive plasma drug screening for cocaine or amphetamine in adult emergency department seizure patients. METHODS: This prospective study evaluated consecutive eligible seizure patients who had a plasma sample collected as part of their clinical evaluation. Plasma was tested for amphetamine and the cocaine metabolite benzoylecgonine using enzyme-mediated immunoassay methodology. Plasma samples with benzoylecgonine greater than 150 ng/mL or an amphetamine greater than 500 ng/mL were defined as positive. Patient demographics, history of underlying drug or alcohol-related seizure disorder, estimated time from seizure to sample collection, history or suspicion of cocaine or amphetamine abuse, results of clinical urine testing for drugs of abuse, and assay results were recorded without patient identifiers. RESULTS: Fourteen of 248 (5.6%, 95% CI 2.7%-8.5%) plasma samples were positive by immunoassay testing for benzoylecgonine and no samples (0%, 95% CI 0-1.2%) were positive for amphetamine. Positive test results were more common in patient visits where there was a history or suspicion of cocaine or amphetamine abuse (p < 0.0005). CONCLUSIONS: During this study period, routine plasma screening for cocaine and amphetamines in adult seizure patients had a low yield. As a result, routine plasma screening would yield few cases of stimulant drug in which there was neither a history nor suspicion of drug abuse in this population.     

Routine screening for risky alcohol consumption at an emergency department using the AUDIT-C questionnaire

A questionnaire including the three AUDIT-C items was used to screen for alcohol use among trauma patients. The aim was to display, in a pragmatic way, how the AUDIT-C scores can be converted into different levels and kind of risky drinking. Using AUDIT-C scores with a cut-off score of 4 points for women and 5 for men indicated that 28% of the women and 40% of the men were risky drinkers. When calculating weekly alcohol consumption from the answers in AUDIT-C, 3% of the women and 7% of the men were hazardous and/or harmful drinkers. Regarding heavy episodic drinking 7% of the women and 30% of the men was drinking 72g alcohol or more at on at least one occasion a month. These results indicate that the AUDIT-C score as such give little information about the pattern of alcohol consumption and that evaluation of risky drinking must be calculated from the three items in order to differentiate between risky drinking in terms of alcohol consumed per week and heavy episodic drinking.     

Attitude changes among emergency department triage staff after conducting routine alcohol screening

Excessive alcohol consumption is common among injury patients, but routine alcohol interventions seem to be difficult to implement in emergency departments. An obstacle seen in previous studies is the limited time available in a real-world setting for staff to participate in routine alcohol screening and interventions. In the present study, ordinary staff participated in a simple alcohol screening procedure. The aim of the study was to evaluate the feasibility of this procedure and if there was any change in attitudes and practices among triage staff after the implementation. We analyzed interviews with six staff members and questionnaires completed by 29 nurses and medical secretaries before and after a period of systematic routine screening. The staff reported that the routine worked well and that few patients reacted negatively. A positive change was seen in attitudes towards alcohol preventive measures in general. However, this seems not to be sufficient for the staff to spontaneously engage more actively. In fact, more of the staff were uncertain after the study period whether the emergency department is an appropriate place for alcohol screening and intervention despite an increased role legitimacy and perceived competence. There is a need for further development of alcohol prevention models that are acceptable for the staff to implement as part of the daily routine.     

The effect of alcohol consumption on emergency department services use among injured patients: A cross-national emergency room study

OBJECTIVE: Although injured patients in the emergency department (ED) report more frequent use of the ED compared with the general population, and alcohol-related admissions and chronic alcohol misuse have been found to be predictive of future ED admissions, these data are based on only a few U.S. studies. The purpose of this article was to explore the association of alcohol use and ED services use among injured patients cross-nationally. METHOD: Binary and multinomial logistic regression were used to analyze the association of alcohol consumption with prior ED visits among 9,743 injured patients surveyed in 37 EDs in 14 countries and reported in 23 studies from the combined Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and World Health Organization Collaborative Study of Alcohol and Injuries. RESULTS: Drinking within 6 hours before injury was associated with prior ED visits during the last 12 months (odds ratio = 1.25, p < .05), with a positive dose-response relationship. Heavy drinkers and those drinkers who were alcohol-dependent were also significantly more likely to report multiple prior ED visits, reflecting an elevated burden of services use. At the ED level, stigmatization of alcohol use was the only significant contextual variable that consistently predicted cross-ED variation in the relationship between drinking and ED use, in which the association was weaker in areas where alcohol use is less accepted. CONCLUSIONS: This study lends additional support to the potential effectiveness of screening for acute and chronic alcohol use among ED injured patients to reduce ED services use and associated costs.     

Selection of screening items for alcohol abuse and alcohol dependence among Mexicans and Mexican Americans in the emergency department.

OBJECTIVE: This article reports on the selection of screening items to detect Mexican or Mexican-American patients in the emergency department (ED) who have alcohol problems and could benefit from an intervention or a referral for treatment. Items are tested against the Rapid Alcohol Problems Screen (RAPS), which has been optimized from standard screening instruments and has outperformed these instruments. METHOD: The performance of individual items from standard screening instruments (CAGE, TWEAK, AUDIT, TRAUMA and BMAST) against International Classification of Diseases, Tenth Revision and Diagnostic and Statistical Manual, Fourth Revision criteria for alcohol abuse and dependence was evaluated in a merged probability sample (N = 869; 72% men) of 537 ED patients from three hospitals in Pachuca, Mexico, and 332 Mexican-American ED patients in Santa Clara County, CA. Logistic regression and tree-classification models were used for item selection. RESULTS: We found a prevalence of 15% for alcohol dependence and a prevalence of 28% for alcohol abuse or dependence in the merged sample. The RAPS items did not perform as well in terms of sensitivity (93%) as the optimal five items identified in these analyses (sensitivity = 98%) for alcohol dependence, but did demonstrate better specificity (79%) than the optimal five items (65%), which is an important consideration in a time of cost containment. Both sets of items showed better sensitivity and positive predictive value but similar Receiver Operating Characteristic values for respondents in the high acculturation group compared to those at other levels of acculturation. Differences in positive predictive value across all subgroups tended to increase at increased cutpoints, especially for the RAPS. CONCLUSIONS: These analyses suggest that the RAPS performs favorably compared to those items optimized, in this sample of Hispanic ED patients. Based on comparative item performance in these analyses, the RAPS may hold promise as a useful tool for screening for alcohol dependence, but requires further evaluation as a stand-alone instrument in comparison with other standard screening instruments.     

The half-life of the 'teachable moment' for alcohol misusing patients in the emergency department

BACKGROUND: To determine whether the length of time between alcohol-related attendance in the emergency department (ED) and follow-up appointment with an alcohol health worker (AHW) alters attendance rate at the AHW clinic. METHODS: We examined paper and computerized records made by AHWs over a 4-year period, collecting data on the length of time between identification of alcohol misuse and the appointment with the AHW, and whether the appointment was kept. RESULTS: There is an inverse relationship between the length of time between identification of alcohol misuse and AHW appointment and the subsequent likelihood of keeping that appointment. CONCLUSIONS: To maximise attendance rates at AHW clinics, the delay between the identification and intervention for alcohol misusing patients must be kept to a minimum, preferably giving an appointment on the same day as the attendance in the ED.     

Mortality risk in a sample of emergency department patients who use cocaine with alcohol and/or cannabis

Background: Illicit drug use is common among emergency department (ED) patients, yet the association between drug use and subsequent mortality is not well understood. This study examines 36-month mortality rates for a sample of ED patients based on reported use of alcohol, cannabis, and cocaine, both individually and in combination. Methods: Patients (N = 1669) from 2 urban EDs were surveyed at the time of the visit. The patient survey included the Alcohol Smoking and Substance Involvement Screening Test (ASSIST) and information on physical and mental health, health care utilization, and risk factors associated with substance use. ASSIST scores were used to categorize patients into drug risk groups. Mortality information from the National Death Index was used to calculate mortality rates from 2009 to 2012. A Cox regression model identified associations between drug risk groups and mortality while controlling for patient demographics. Results: The use of cocaine and cannabis both individually and in combination was associated with significantly higher mortality risk compared with other ED patients. Conclusions: ED patients who use cannabis and cocaine have higher mortality risks than other patients. Further research is necessary to determine whether this result is stable across racial/ethnic groups.     

Role preferences of patients with alcohol use disorders

AimsShared decision making (SDM) is increasingly demanded in medical decision making. SDM acknowledges patients' role preferences in decision making processes. There has been limited research on SDM and role preferences in substance use disorders; results are promising. Aim of this study was to investigate role preferences of patients with alcohol use disorders (AUD), and to identify predictors of these preferences.MethodCross-sectional data collected from June 2013 to May 2014 in four detoxification wards in Germany during a randomised controlled trial (RCT, Registration Code 01GY1114) was analysed.Of the 250 patients with AUD who were included in the RCT, data from 242 patients [65% male; mean age = 45.2 years (sd = 10.3)] were analysed. Participants' role preferences were assessed with the Control Preference Scale. Potential correlates were drawn from instruments used in the RCT; multinomial logistic regression was used.Results90% (n = 217) of the AUD patients preferred an active or shared role in decision-making, 10% (n = 25) preferred a passive role. Patients' desire for help was associated with their role preference (OR = 3.087, p = .05). The model's goodness of fit was Nagelkerke's R² = 0.153 [χ² (24) = 25.206, p = .395].ConclusionsPatients' preference for an active role in decision-making underscores the importance of involving patients in their treatment planning. Patients' desire for help seems to be an important determinant of paternalistic decision making. However, further research is needed to determine whether patients' role preferences are related to their behavior during their treatment referral and recovery.     

Cost-effectiveness of screening and referral to an alcohol health worker in alcohol misusing patients attending an accident and emergency department: a decision-making approach

We present the cost and cost-effectiveness of referral to an alcohol health worker (AHW) and information only control in alcohol misusing patients. The study was a pragmatic randomised controlled trial conducted from April 2001 to March 2003 in an accident and emergency department (AED) in a general hospital in London, England. A total of 599 adults identified as drinking hazardously according to the Paddington Alcohol Test were randomised to referral to an alcohol health worker who delivered a brief intervention (n = 287) or to an information only control (n = 312). Total societal costs, including health and social services costs, criminal justice costs and productivity losses, and clinical measures of alcohol consumption were measured. Levels of drinking were observably lower in those referred to an AHW at 12 months follow-up and statistically significantly lower at 6 months follow-up. Total costs were not significantly different at either follow-up. Referral to AHWs in an AED produces favourable clinical outcomes and does not generate a significant increase in cost. A decision-making approach revealed that there is at least a 65% probability that referral to an AHW is more cost-effective than the information only control in reducing alcohol consumption among AED attendees with a hazardous level of drinking.     

Comparative performance of the AUDIT-C in screening for DSM-IV and DSM-5 alcohol use disorders

Objective

Under the proposed DSM-5 revision to the criteria for alcohol use disorder (AUD), a substantial proportion of DSM-IV AUD cases will be lost or shifted in terms of severity, with some new cases added. Accordingly, the performance of the AUDIT-C in screening for DSM-IV AUD cannot be assumed to extend to DSM-5 AUD. The objective of this paper is to compare the AUDIT-C in screening for DSM-IV and DSM-5 AUD.

Methods

Using a broad range of performance metrics, the AUDIT-C was tested and contrasted as a screener for DSM-IV AUD (any AUD, abuse and dependence) and DSM-5 AUD (any AUD, moderate AUD and severe AUD) in a representative sample of U.S. adults aged 21 and older and among past-year drinkers.

Results

Optimal AUDIT-C cutpoints were identical for DSM-IV and DSM-5 AUD: ≥4 for any AUD, ≥3 or ≥4 for abuse/moderate AUD and ≥4 or ≥5 for dependence/severe AUD. Screening performance was slightly better for DSM-5 severe AUD than DSM-IV dependence but did not differ for other diagnoses. At optimal screening cutpoints, positive predictive values were slightly higher for DSM-5 overall AUD and moderate AUD than for their DSM-IV counterparts. Sensitivities were slightly higher for DSM-5 severe AUD than DSM-IV dependence. Optimal screening cutpoints shifted upwards for past-year drinkers but continued to be identical for DSM-IV and DSM-5 disorders.

Conclusions

Clinicians should not face any major overhaul of their current screening procedures as a result of the DSM-5 revision and should benefit from fewer false positive screening results.     

Acceptability of a computerized alcohol screening and advice routine in an emergency department setting--a patient perspective

Disseminating screening and brief alcohol intervention in routine emergency department (ED) care seems to be a demanding challenge due to the complexity of the emergency setting. Further empirical realistic intervention models need to be developed that are appropriate for staff and patients before such models are tested in large scale controlled trials. This study explores patients' acceptance of a computerized opportunistic alcohol screening, followed by a personalized printout as feedback, at an emergency department performed by ordinary emergency department staff. In all, 44 patients were interviewed after performing the computerized screening test. The majority of patients were positive about answering the questions about alcohol habits, and 95% found it easy to use the touch screen and understand the instructions, even those with little computer experience. Regarding the personalized printout of advice, 76% were positive to this kind of feedback and 93% said they would read the printout. Most patients, 74%, preferred the computerized printout instead of a more personalized feedback from staff members. Whether the computerized advice is sufficient for a change in alcohol habits among excessive drinkers is still to be shown in controlled trials, but the concept could be one means of making preventive measures more feasible in a real-world ED setting. This might provide a basis for dissemination and integration of more extensive interventions in the long term.