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.     

Screening for problem drinking

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. This research was supported by Department of Veteran Affairs, Hines Center for Cooperative Studies in Health Services Research, grant 91-007, and Health Services Research and Development, grant SDR 96-002, Ambulatory Care Quality Improvement Project (ACQUIP); a grant from the University of Washington Alcohol and Drug Abuse Institute; and the Health Services Research and Development Field Program and Medical Service, Seattle Division, VA Pudget Sound Health Care System.     

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.     

Comparing the alcohol-related problems survey (ARPS) to traditional alcohol screening measures in elderly outpatients

Older drinkers may incur alcohol-related risks at low consumption levels, but commonly used screening measures do not address alcohol's effects among persons with declining health and increased medication use. We compared the newly developed Alcohol-Related Problems Survey (ARPS) to three validated alcohol screens: the Cut down, Annoyed, Guilty, Eye-opener (CAGE), Short-Michigan Alcohol Screening Test (SMAST), and Alcohol-Use Identification Test (AUDIT). The ARPS classifies drinking as non-hazardous, hazardous or harmful. Non-hazardous drinking is defined as consumption with no known risks for adverse physical or psychological health events. Hazardous drinking is consumption with such risks. Harmful drinking results in adverse events. The AUDIT screens for hazardous and harmful drinking; the CAGE and SMAST identify abusive (e.g. failure to fulfill social obligations) and dependent (e.g. having withdrawal symptoms) drinkers. In this study of 574 current drinkers 65 years and older who completed the ARPS and AUDIT in primary care clinics, half were randomly assigned to complete the CAGE and half, the SMAST. Drinkers who screened positive on the CAGE, SMAST or AUDIT were correctly classified by the ARPS as hazardous or harmful drinkers 91, 75, and 100% of the time, respectively. The majority of ARPS-identified hazardous or harmful drinkers did not screen positive on the CAGE, SMAST or AUDIT. These drinkers had medical conditions or used medications that placed them at risk for adverse health events, none of which was addressed in these three screens. In this study, the ARPS identified nearly all drinkers detected by the CAGE, SMAST, and AUDIT and detected hazardous and harmful drinkers not identified by these measures.     

Alcohol screening scores and risk of hospitalizations for GI conditions in men

BACKGROUND: Alcohol misuse is a common cause of liver disease, upper gastrointestinal (GI) bleeding, and pancreatitis, but it is not known whether alcohol screening questionnaires can identify patients at increased risk for hospitalizations due to these conditions. OBJECTIVE: To evaluate the association of alcohol screening scores with the risk of subsequent hospitalization for alcohol-related GI conditions. DESIGN: Retrospective cohort study. PARTICIPANTS: Male general medicine outpatients from 7 Veterans Affairs (VA) medical centers who returned mailed questionnaires. MEASUREMENTS: The CAGE questionnaire (0-4 points) and the Alcohol Use Disorders Identification Test-Consumption questions (AUDIT-C; 0-12 points) were included on mailed surveys. The main outcome, "GI hospitalization," was a primary VA or Medicare discharge diagnosis indicating liver disease, upper GI bleeding, or pancreatitis. RESULTS: Among 31,311 patients followed, a median of 3.75 years, patients with CAGE scores >or=2 points or AUDIT-C scores >or=6 points were at a significantly increased risk for GI hospitalizations. Adjusted hazard ratios (HR(adj)) ranged from 1.6 (95% CI 1.2-2.0) for CAGE score 2, to 1.7 (1.4-2.2) for CAGE 4, and from 1.4 (1.01-2.0) for AUDIT-C scores from 6 to 7, to 2.7 (1.9-3.8) for AUDIT-C scores from 10 to 12. Secondary analyses demonstrated that the association was the strongest among patients less than 50 years of age who reported drinking in the past year. CONCLUSIONS: Brief alcohol screening questionnaires predict subsequent hospitalizations for alcohol-related GI conditions.     

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.     

The value of CAGE, CUGE, and AUDIT in screening for alcohol abuse and dependence among college freshmen

BACKGROUND: This study attempted to (1) determine the prevalence of alcohol problems in college freshmen, (2) assess the performance of both the CAGE and the Alcohol Use Disorders Identification Test (AUDIT) questionnaires in this population, and (3) assess the possibility of improving the CAGE and/or AUDIT. METHODS: A sample of 3564 consecutive college freshmen, with a mean age of 18 years, at the Catholic University of Leuven, (Belgium) completed, during a cross-sectional study, a questionnaire assessing drinking behavior and identifying students at risk as defined by DSM-IV criteria. The questionnaire also included the CAGE questionnaire and the AUDIT. Calculations of sensitivity, specificity, negative predictive value, positive predictive value, likelihood ratios, and receiver operating characteristic curves for different scores of the CAGE and the AUDIT were performed, using DSM-IV criteria as the reference standard. RESULTS: The area under the receiver operating characteristic curve of the CAGE and the AUDIT was 0.76 and 0.85, respectively. The cutoff score of 1 for the CAGE was associated with a sensitivity of 42%, a specificity of 87%, a positive predictive value of 36%, and a negative predictive value of 90%. A score of 6 or more for the AUDIT gave a sensitivity of 80%, a specificity of 78%, a positive predictive value of 37%, and a negative predictive value of 77%. These results were related with a prevalence of 14.1% of alcohol problems. Replacing one question of the CAGE by "often driving under the influence" resulted in the CUGE (acronym for "cut down, under influence, guilty feelings, and eye opener"), with an area under the curve of 0.96, a positive likelihood ratio of 8.7, and a negative likelihood ratio of 0.04. CONCLUSIONS: Prevalence of alcohol problems in college students is confirmed to be high. When screening for alcohol problems in a college freshmen population, one question seems extremely important. The newly constructed CUGE questionnaire may improve screening efforts in students, compared with existing questionnaires.     

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.     

Effectiveness of the Alcohol Use Disorders Identification Test in Occupational Health Screenings

This study evaluated the effectiveness of the 10-item Alcohol Use Disorders Identification Test (AUDIT) among occupational health screenings. AUDIT was available from 32 male and 93 female employees, mainly of academic organizations; 22 alcoholic men reporting to treatment at a detoxification clinic served as a reference group. Two other structured questionnaires, the Malmö modified Michigan Alcoholism Screening Test (Mm-MAST) and the CAGE, were compared with the AUDIT, and comparisons were also made to the self-reported weekly alcohol consumption. The total score on the AUDIT correlated equally with the self-reported alcohol consumption, especially when the alcoholics were excluded ( r = 0.73, p < 0.001) as the Mm-MAST ( r = 0.58, p < 0.001) and CAGE ( r = 0.33, p = 0.005). All three questionnaires were good at detecting male alcoholics: using the cut-off point of at least 8 positive answers on the AUDIT, 3 on the Mm-MAST, and 3 on the CAGE. The sensitivities were 100%, 100%, and 91%, respectively. In the AUDIT, however, there was a clearer difference related to the cut-off level than with the Mm-MAST and CAGE. With the cut-off of 8 points, 31% of the male and 11 % of the female employees were classified as suspect heavy drinkers. The AUDIT was significantly more often accurate than the two other questionnaires, especially among female employees in detecting suspect early-phase heavy drinkers and thus seems to be suitable for health screenings.     

Alcohol screening results in elderly male veterans: association with health status and mortality

OBJECTIVES: To evaluate the association between alcohol screening results and health status or mortality in elderly patients. DESIGN: Cross-sectional and longitudinal cohort studies. SETTING: Primary care clinics at seven Veterans Affairs medical centers. PARTICIPANTS: A total of 16,958 male patients aged 65 and older. MEASUREMENTS: Alcohol screening questionnaires were used to divide patients into four mutually exclusive groups: drinkers who screened negative or positive for problem drinking and nondrinkers (in the previous year) who screened negative or positive for problem drinking. A subset of patients (n=12,491) completed a measure of health status, the Medical Outcomes Study Short Form (SF-36). All-cause mortality was ascertained using Veterans Affairs data over a mean follow-up of 2.8 years. RESULTS: Forty-eight percent of participants reported drinking in the previous year. Half of the drinkers and nondrinkers screened positive for problem drinking. The SF-36 item scores were consistently higher for drinkers than for nondrinkers and for patients who screened negative for problems than for those who screened positive. Similarly, survival was consistently better in drinkers than nondrinkers (mortality hazard ratio (HR)=0.74, 95% confidence interval (CI)=0.68-0.82) and in patients who screened negative for problem drinking than in those who screened positive (mortality HR=0.87, 95% CI=0.80-0.95). Nondrinkers who screened positive for problem drinking had the poorest health status and survival, whereas drinkers who screened negative for problem drinking had the best health status and survival. CONCLUSION: Elderly patients who reported drinking alcohol and those who screened negative for problem drinking had consistently better health status and survival than those who did not drink and those who screened positive.     

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.     

Effectiveness of structured questionnaires for screening heavy drinking in middle-aged women

BACKGROUND: There is a need for an effective and feasible alcohol screening instrument. The aim of the study was to evaluate how the abbreviated versions of the Alcohol Use Disorders Identification Test (AUDIT) questionnaire perform in comparison with the original AUDIT and what the optimal cutoffs are when screening for heavy drinking among women. METHODS: All the 40-year-old women in the city of Tampere, Finland, are invited yearly for a health screening. From 1 year, data from 894 women (response rate 68.2%) invited for a health screening were utilized in the study. The original 10-item AUDIT, AUDIT-C, Five Shot, AUDIT-PC, AUDIT-3, AUDIT-QF, and CAGE were evaluated against the Timeline Followback. Consumption of at least 140 g of absolute ethanol per week on average during the past month was considered heavy drinking. RESULTS: In the Timeline Followback, the mean+/-SD weekly reported alcohol consumption was 45+/-67 g (range 0-936 g) of absolute ethanol. Of the women, 6.2% (55/894) were heavy drinkers. The optimal combination of sensitivity and specificity was reached for the AUDIT with cutoff > or =6, for the AUDIT-C with cutoff > or =5, for the Five Shot with cutoff > or =2.0, for the AUDIT-PC with cutoff > or =4, and for the AUDIT-QF with cutoff > or =4. When choosing the optimal cutoffs, the AUDIT-C, the Five Shot, the AUDIT-PC, and the AUDIT-QF performed as well as the 10-item AUDIT. With these cutoffs, sensitivities were 0.84 to 0.93 and specificities were 0.83 to 0.90. The AUDIT-3 and the CAGE did not perform as well as the other questionnaires. CONCLUSIONS: The 10-item AUDIT, AUDIT-C, Five Shot, AUDIT-PC, and AUDIT-QF seem to be equally effective tools in screening for heavy drinking among middle-aged women. However, their applicability is achieved only if the cutoffs are tailored according to gender.     

ADH1B*2 allele is protective against alcoholism but not chronic liver disease in the Hungarian population

Background Standardized death rates from chronic liver diseases (CLDs) in Hungary are much higher than the European Union average. Carrying the alcohol dehydrogenase 1B 48His allele (rs1229984 or ADH1B*2) could decrease the risk of alcoholism, but with persistent drinking may confer a greater risk of CLDs. The aim of this study was to assess the prevalence of this polymorphism in the Hungarian population and its association with alcohol consumption and with CLDs. Methods and results A total of 278 cases with diagnosed CLDs and 752 controls without any alterations in liver function, all males aged 45–64, were screened for ADH1B Arg48His polymorphism. ADH1B*2 allele frequencies in controls and cases were 8.31% and 4.50%, respectively (χ² = 9.2; P = 0.01). Carrying the ADH1B*2 allele was associated with significantly lower odds ratio (OR) for drinking frequency (OR = 0.63; P = 0.003), the number of positive answers on CAGE (Cut‐down, Annoyed, Guilt, Eye‐opener) assessment (OR = 0.58; P = 0.005) and a positive CAGE status (OR = 0.55; P = 0.007). There was a significant association between ADH1B*2 and CLDs (OR = 0.50; P = 0.003), but it disappeared after adjusting for CAGE status and scores (OR = 0.67 P = 0.134; OR = 0.67 P = 0.148, respectively) and weakened after adjusting for drinking frequency (OR = 0.61; P = 0.045). Among heavy drinkers the presence of ADH1B*2 did not increase the risk of cirrhosis but there was a significant interaction between genotype and CAGE status (P = 0.003, P = 0.042), with ADH1B*2 conferring reduced risk of CLDs in CAGE negatives. Conclusion In Hungarians, the ADH1B 48His allele reduces the risk of alcoholism, but not the risk of chronic liver disease among heavy drinkers.     

The TWEAK is weak for alcohol screening among female Veterans Affairs outpatients

BACKGROUND: The optimal brief questionnaire for alcohol screening among female patients has not yet been identified. This study compared the performance of the TWEAK (tolerance, worried, eye-opener, amnesia, cutdown), the Alcohol Use Disorders Identification Test (AUDIT), and the AUDIT Consumption (AUDIT-C) as self-administered screening tests for hazardous drinking and/or active alcohol abuse or dependence among female Veterans Affairs (VA) outpatients. METHODS: Women were included in the study if they received care at VA Puget Sound and completed both a self-administered survey containing the AUDIT and TWEAK screening questionnaires and subsequent in-person interviews with the Alcohol Use Disorders and Associated Disabilities Interview Schedule. Sensitivities, specificities, positive and negative likelihood ratios, and areas under Receiver Operating Characteristic curves were computed for each screening questionnaire compared with two interview-based comparison standards: (1) active DSM-IV alcohol abuse or dependence and (2) hazardous drinking and/or active DSM-IV alcohol abuse or dependence, the more appropriate target for primary care screening. RESULTS: Of 393 women who completed screening questionnaires and interviews, 39 (9.9%) met diagnostic criteria for alcohol abuse or dependence, and 89 (22.7%) met criteria for hazardous drinking or alcohol abuse or dependence. The TWEAK had relatively low sensitivities (0.62 and 0.44) but adequate specificities (0.86 and 0.89) for both interview-based comparison standards, even at its lowest cut-point (>/=1). The AUDIT and AUDIT-C were superior, with the following areas under the receiver operating characteristic curve for active alcohol abuse or dependence and hazardous drinking and/or active alcohol abuse or dependence, respectively: AUDIT, 0.90 [95% confidence interval (CI), 0.85-0.95] and 0.87 (95% CI, 0.84-0.91); AUDIT-C, 0.91 (95% CI, 0.88-0.95) and 0.91 (95% CI, 0.88-0.94); and TWEAK, 0.76 (95% CI, 0.66-0.86) and 0.67 (95% CI, 0.60-0.74). CONCLUSIONS: The TWEAK has low sensitivity as an alcohol-screening questionnaire among female VA outpatients and should be evaluated further before being used in other female primary care populations. The three-item AUDIT-C was the optimal brief alcohol-screening questionnaire in this study.     

Moderators and mediators of two brief interventions for alcohol in the emergency department

Objective To evaluate moderators and mediators of brief alcohol interventions conducted in the emergency department. Methods Patients (18–24 years; n = 172) in an emergency department received a motivational interview with personalized feedback (MI) or feedback only (FO), with 1‐ and 3‐month booster sessions and 6‐ and 12‐month follow‐ups. Gender, alcohol status/severity group [ALC+ only, Alcohol Use Disorders Identification Test (AUDIT+) only, ALC+/AUDIT+], attribution of alcohol in the medical event, aversiveness of the event, perceived seriousness of the event and baseline readiness to change alcohol use were evaluated as moderators of intervention efficacy. Readiness to change also was evaluated as a mediator of intervention efficacy, as were perceived risks/benefits of alcohol use, self‐efficacy and alcohol treatment seeking. Results Alcohol status, attribution and readiness moderated intervention effects such that patients who had not been drinking prior to their medical event, those who had low or medium attribution for alcohol in the event and those who had low or medium readiness to change showed lower alcohol use 12 months after receiving MI compared to FO. In the AUDIT+ only group those who received MI showed lower rates of alcohol‐related injury at follow‐up than those who received FO. Patients who had been drinking prior to their precipitating event did not show different outcomes in the two interventions, regardless of AUDIT status. Gender did not moderate intervention efficacy and no significant mediation was found. Conclusions Findings may help practitioners target patients for whom brief interventions will be most effective. More research is needed to understand how brief interventions transmit their effects.     

Assessment of alcohol use among methadone maintenance patients by direct ethanol metabolites and self-reports

Background: Heavy alcohol consumption may accelerate the progression of hepatitis C (HCV)‐related liver disease and/or limit efforts at antiviral treatment. As most of the patients in methadone maintenance treatment (MMT) suffer from hepatitis C infection, this study was conducted to identify the alcohol intake among these patients at a Swiss Psychiatric University Clinic by self‐reports and direct ethanol metabolites as biomarkers of ethanol consumption. Patients and Methods: A convenience sample of 40 MMT patients (15 women, 25 men; median age 39 years) of the total 124 patients was asked and consented to participate in this study. This sample was not different in age, gender distribution, and rate of hepatitis C infection from the total sample. The Alcohol Use Disorders Identification Test (AUDIT) and self‐reported ethanol intake during the previous 7 days were assessed. In addition, ethyl glucuronide (EtG) in urine, and fatty acid ethyl esters (FAEEs) and EtG in hair were determined using LC‐MS/MS and gas chromatograph/mass spectrometer. The limit of quantitation for UEtG, HEtG, and FAEEs were 0.1 mg/l, 2.3 pg/mg, and 0.1 ng/mg, respectively. Results: Fourteen participants reported abstinence from alcohol for the previous 7 days. AUDIT scores were ≥8 in 15 male and >5 in 5 female participants. Direct ethanol metabolites were as follows (median, min, max, standard deviation): UEtG (19 positives; 9.91, 1.38 to 251, 62.39 mg/l); the values of HEtG were 17.65, 0 to 513, 105.62 pg/mg [in 2 cases no material, 8 abstinent (up to 7 pg/mg), 15 social drinkers (up to 50 g per day), and 15 excessive users (>50/60 g/d)]. For the 13 cases, where enough material for additional determination of HFAEEs was available, the values were 0.32, 0 to 1.32, 0.44 ng/mg. Among the 30 HEtG‐positive participants, 20 had not reported the corresponding ethanol intake using question 1 (frequency) and 2 (quantity) of the AUDIT. Of the 14 participants reporting no alcohol intake during the previous 7 days, 4 were UEtG‐positive. HEtG and AUDIT correlated significantly (r = 0.622, p < 0.0001), but this was not the case for UEtG and self‐reported ethanol intake during the previous 7 days. Conclusion: (1) HEtG identified 20 cases of daily ethanol intake of more than 20 g, that would have been missed by the sole use of question 1 (frequency) and 2 (quantity) of the AUDIT. (2) Using the total score of the AUDIT, HEtG confirmed 10 more cases positive for alcohol intake. (3) Episodic heavy drinking is with 22.5% more frequent than in general population, and (4) of the 14 participants who reported no alcohol intake during the previous 7 days, 4 were UEtG positive. Improved detection of alcohol consumption, which is hazardous or harmful in the context of HCV and opiate dependence, would allow for earlier intervention in this population which is at particular risk of liver disease and fatal respiratory‐depressed overdose. The combined use of self‐reports and direct ethanol metabolites seems promising.     

Interactive Effects of Cumulative Stress and Impulsivity on Alcohol Consumption

Background: Alcohol addiction may reflect adaptations to stress, reward, and regulatory brain systems. While extensive research has identified both stress and impulsivity as independent risk factors for drinking, few studies have assessed the interactive relationship between stress and impulsivity in terms of hazardous drinking within a community sample of regular drinkers. Methods: One hundred and thirty regular drinkers (56M/74F) from the local community were assessed for hazardous and harmful patterns of alcohol consumption using the Alcohol Use Disorders Identification Test (AUDIT). All participants were also administered the Barratt Impulsiveness Scale (BIS‐11) as a measure of trait impulsivity and the Cumulative Stress/Adversity Checklist (CSC) as a comprehensive measure of cumulative adverse life events. Standard multiple regression models were used to ascertain the independent and interactive nature of both overall stress and impulsivity as well as specific types of stress and impulsivity on hazardous and harmful drinking. Results: Recent life stress, cumulative traumatic stress, overall impulsivity, and nonplanning‐related impulsivity as well as cognitive and motor‐related impulsivity were all independently predictive of AUDIT scores. However, the interaction between cumulative stress and total impulsivity scores accounted for a significant amount of the variance, indicating that a high to moderate number of adverse events and a high trait impulsivity rating interacted to affect greater AUDIT scores. The subscale of cumulative life trauma accounted for the most variance in AUDIT scores among the stress and impulsivity subscales. Conclusions: Findings highlight the interactive relationship between stress and impulsivity with regard to hazardous drinking. The specific importance of cumulative traumatic stress as a marker for problem drinking is also discussed.     

Five-Shot Questionnaire on Heavy Drinking

To develop an effective, but short, questionnaire to detect heavy drinking, we combined two questions from AUDIT and three from CAGE. We have tested earlier this new Five-Shot questionnaire among male alcoholics who all had a total score of at least 4/7. The purpose of the present study was to find out the effectiveness of the Five-Shot questionnaire among middle-aged men. In the present study, the Five-Shot questionnaire was distributed to all ( n = 853) 40-year-old men attending health screening in a Finnish town. The participation percentage in the screening was 70.3%. Self-reported alcohol consumption was used as a gold standard; 557 of these men gave a self-report that they consumed less absolute alcohol than 140 g/week (moderate drinkers), and 70 reported consuming ≥280 g/week (heavy drinkers). None of the individual Five-Shot questions was superior to any other in detecting heavy drinkers. The cut-off point ≥3 for Five-Shot gave a 77% sensitivity in detecting heavy drinkers, with a specificity of 83% and an overall accuracy of 83%. The corresponding figures with ≥2.5 cut-off were 96%, 76%, and 78%. The commonly used cut-off for CAGE, ≥2, gave a result of 47%, 87%, and 83%, respectively. The area under the receiver operating characteristic curve for the CAGE was clearly worse, compared with that of the Five-Shot. The new Five-Shot questionnaire seems to be efficient in differentiating between moderate and heavy drinkers. It is also easy and fast for physicians to use in different health-care settings. Thus, it can serve as a good aid in early detection of heavy drinking.     

Is the Full Version of the AUDIT Really Necessary? Study of the Validity and Internal Construct of Its Abbreviated Versions

Background: This study was aimed at assessing the psychometric qualities of the abbreviated versions of the Alcohol Use Disorders Identification Test (AUDIT‐3, AUDIT‐4, AUDIT‐C, AUDIT‐PC, AUDIT‐QF, FAST, and Five‐Shot) and at comparing them to the 10‐item AUDIT and the CAGE in 2 samples of Brazilian adults. Methods: The validity and internal consistency of the scales were assessed in a sample of 530 subjects attended at an emergency department and at a Psychosocial Care Center for Alcohol and Drugs. The Structured Clinical Interview for DSM‐IV was used as the diagnostic comparative measure for the predictive validity assessment. The concurrent validity between the scales was analyzed by means of Pearson’s correlation coefficient. Results: The assessment of the predictive validity of the abbreviated versions showed high sensitivity (of 0.78 to 0.96) and specificity (of 0.74 to 0.94) indices, with areas under the curve as elevated as those of the AUDIT (0.89 and 0.92 to screen for abuse and 0.93 and 0.95 in the screening of dependence). The CAGE presented lower indices: 0.81 for abuse and 0.87 for dependence. The analysis of the internal consistency of the AUDIT and its versions exhibited Cronbach’s alpha coefficients between 0.83 and 0.94, while the coefficient for the CAGE was 0.78. Significant correlations were found between the 10‐item AUDIT and its versions, ranging from 0.91 to 0.99. Again, the results for the CAGE were satisfactory (0.77), although inferior to the other instruments. Conclusions: The results obtained in this study confirm the validity of the abbreviated versions of the AUDIT for the screening of alcohol use disorders and show that their psychometric properties are as satisfactory as those of the 10‐item AUDIT and the CAGE.