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.     

Energy drink consumption and increased risk for alcohol dependence

Background: Energy drinks are highly caffeinated beverages that are increasingly consumed by young adults. Prior research has established associations between energy drink use and heavier drinking and alcohol‐related problems among college students. This study investigated the extent to which energy drink use might pose additional risk for alcohol dependence over and above that from known risk factors. Methods: Data were collected via personal interview from 1,097 fourth‐year college students sampled from 1 large public university as part of an ongoing longitudinal study. Alcohol dependence was assessed according to DSM‐IV criteria. Results: After adjustment for the sampling design, 51.3%_wt of students were classified as “low‐frequency” energy drink users (1 to 51 days in the past year) and 10.1%_wt as “high‐frequency” users (≥52 days). Typical caffeine consumption varied widely depending on the brand consumed. Compared to the low‐frequency group, high‐frequency users drank alcohol more frequently (141.6 vs. 103.1 days) and in higher quantities (6.15 vs. 4.64 drinks/typical drinking day). High‐frequency users were at significantly greater risk for alcohol dependence relative to both nonusers (AOR = 2.40, 95% CI = 1.27 to 4.56, p = 0.007) and low‐frequency users (AOR = 1.86, 95% CI = 1.10, 3.14, p = 0.020), even after holding constant demographics, typical alcohol consumption, fraternity/sorority involvement, depressive symptoms, parental history of alcohol/drug problems, and childhood conduct problems. Low‐frequency energy drink users did not differ from nonusers on their risk for alcohol dependence. Conclusions: Weekly or daily energy drink consumption is strongly associated with alcohol dependence. Further research is warranted to understand the possible mechanisms underlying this association. College students who frequently consume energy drinks represent an important target population for alcohol prevention.     

Is There a Difference Between CAGE Interviews and Written CAGE Questionnaires?

Background: The CAGE questionnaire is a frequently studied and used instrument for screening of alcohol problems. It was developed and tested as a written questionnaire, but, clinically, it is often used as an oral interview. No comparisons have been made between the results of a written and an oral CAGE. This study attempted to (1) compare the results of a written CAGE questionnaire and a CAGE interview, and (2) compare the efficiency of using a simple open‐ended question about drinking habits before asking the CAGE and asking the CAGE without an introduction. Methods: All patients who attended a general internal medicine, cardiology, or hepatology clinic were classified according to the week of the consultation, as follows: group I (week 1), patients completed a written CAGE and were subsequently interviewed during a normal consultation by a physician, who also asked the CAGE questions; group II (week 2), a physician first interviewed the patients, including the CAGE, and subsequently patients completed a written CAGE; and group III (week 3), patients completed a CAGE interview after an open‐ended introduction (“What do you drink during the day?”). Kappa values were used to compare the answers of the written and oral CAGE interviews (groups II and I). Nonparametric ANOVA was used to compare the results of group III and the oral interview of group II. Results: Mean age was comparable between the groups, gender ratio was comparable between groups I and III, but there were fewer males in group II. Comparison of all written CAGEs with the oral CAGEs in the same patients resulted in an accuracy of 0.91 and a kappa value of 0.75 (95% CI, 0.66–0.84). No significant difference could be found between the results of the oral CAGE with or without an open‐ended introduction (p= 0.46). Conclusions: We found no difference between the oral and the written versions of the CAGE. This is important because most research results originate from written questionnaires. Our results do not support the finding that a different approach to the CAGE questions results in an increasing number of patients in which alcohol problems were detected.     

Alcohol Availability and Intimate Partner Violence Among US Couples

Objectives: We examined the relation between alcohol outlet density (the number of alcohol outlets per capita by zip code) and male‐to‐female partner violence (MFPV) or female‐to‐male partner violence (FMPV). We also investigated whether binge drinking or the presence of alcohol‐related problems altered the relationship between alcohol outlet density and MFPV or FMPV. Methods: We linked individual and couple sociodemographic and behavioral data from a 1995 national population‐based sample of 1,597 couples to alcohol outlet data and 1990 US Census sociodemographic information. We used logistic regression for survey data to estimate unadjusted and adjusted odds ratios between alcohol outlet density and MFPV or FMPV along with 95% confidence intervals (CIs) and p‐values. We used a design‐based Wald test to derive a p‐value for multiplicative interaction to assess the role of binge drinking and alcohol‐related problems. Results: In adjusted analysis, an increase of one alcohol outlet per 10,000 persons was associated with a 1.03‐fold increased risk of MFPV (p‐value for linear trend = 0.01) and a 1.011‐fold increased risk of FMPV (p‐value for linear trend = 0.48). An increase of 10 alcohol outlets per 10,000 persons was associated with 34% and 12% increased risk of MFPV and FMPV respectively, though the CI for the association with FMPV was compatible with no increased risk. The relationship between alcohol outlet density and MFPV was stronger among couples reporting alcohol‐related problems than those reporting no problems (p‐value for multiplicative interaction = 0.01). Conclusions: We found that as alcohol outlet density increases so does the risk of MFPV and that this relationship may differ for couples who do and do not report alcohol‐related problems. Given that MFPV accounts for the majority of injuries related to intimate partner violence, policy makers may wish to carefully consider the potential benefit of limiting alcohol outlet density to reduce MFPV and its adverse consequences.     

Evaluation of a Japanese version of the Mini‐Mental State Examination in elderly persons

Aim: This study aimed to examine the validity and item‐response characteristics of the Mini‐Mental State Examination (MMSE), which is used for assessing cognitive function, in Japanese older adults. Methods: Factor analysis and item response analysis were carried out for MMSE responses (n = 1971) from older adults living in the community (n = 1339) or in a nursing home (n = 632), including Alzheimer‐type dementia (n = 330), vascular dementia (n = 36), frontotemporal dementia (n = 7), mixed Alzheimer‐type and frontotemporal type dementia (n = 27), and age‐related cognitive decline (n = 29). When choosing the cut‐off score of 23 points for the MMSE, sensitivity and specificity for each item were calculated. Results: A three‐factor solution was found to be most appropriate by factor analysis: complex processing, simple processing and working memory. The item characteristics curves showed unidimensionality with high reproducibility. We identified a simplified scale comprising 10 items in all participants: “naming”, “three‐step command”, “registration”, “repeat a sentence”, “write a complete sentence”, “copies drawing of two polygons”, “orientation to place”, “delayed recall”, “orientation to time” and “serial sevens” tasks. Sensitivity and specificity for both “year” task and “day” task were more than 90% (“year”: sensitivity 92.5%, specificity 96.3%; “day”: sensitivity 92.4%, specificity 91.7%). For the Alzheimer‐type dementia patients, the five‐factor solution was suggested by factor analysis and the MMSE also had unidimensionality in terms of level of difficulty. Conclusions: We found that the MMSE had multiple cognitive areas. We showed that the MMSE could be used as an essentially unidimensional measure of cognitive ability and the question about orientation to time might be useful in the simplest assessment to identify cognitive dysfunction. Geriatr Gerontol Int 2012; 12: 310–316.     

Do drinking games matter? An examination by game type and gender in a mandated student sample

Abstract

Background: College students who violate alcohol policies engage in riskier alcohol use and demonstrate more problems related to their use than non-violating peers. Drinking games (DG) have been linked to increased alcohol use and negative consequences. Objectives: The present study sought to assess potential differences in DG participation among mandated males and females by examining rates of endorsement, types of DG played, and how types of games are related to alcohol use and related consequences. Methods: Participant data were obtained from 154 undergraduate students mandated to receive an alcohol intervention, Results: DG players were found to have higher typical and peak blood alcohol concentrations, consume more drinks per week on average, consume more standard drinks per highest drinking occasion, and to experience a considerably greater number of alcohol-related consequences than non-players. Males endorsed greater participation in DG and cited “team” and “motor” games more often than females. “Gambling” games were endorsed equally by both sexes, but resulted in increased consequences for females only. Conclusion: Engaging in DG results in higher levels of alcohol consumption. The likelihood of consequences experienced may vary by type of DG in which individuals choose to participate, as well as by gender. Results from this study provide information that can be utilized in targeted alcohol programming efforts, not only for a high-risk population such as mandated students, but tailored to the specific needs of males and females.     

A Double-Blind Trial of Gabapentin Versus Lorazepam in the Treatment of Alcohol Withdrawal

Introduction: Some anticonvulsants ameliorate signs and symptoms of alcohol withdrawal, but have an unacceptable side effect burden. Among the advantages of using anticonvulsant agents in this capacity is their purported lack of interaction with alcohol that could increase psychomotor deficits, increase cognitive impairment, or increase intoxication. The aim of this study was to evaluate alcohol use and symptom reduction of gabapentin when compared with lorazepam in the treatment of alcohol withdrawal in a double‐blinded randomized clinical trial. Methods: One hundred individuals seeking outpatient treatment of alcohol withdrawal with Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA‐Ar) ratings ≥10 were randomized to double‐blind treatment with 2 doses of gabapentin (900 mg tapering to 600 mg or 1200 tapering to 800 mg) or lorazepam (6 mg tapering to 4 mg) for 4 days. Severity of alcohol withdrawal was measured by the CIWA‐Ar on days 1 to 4 of treatment and on days 5, 7, and 12 post‐treatment and alcohol use monitored by verbal report and breath alcohol levels. Results: CIWA‐Ar scores decreased over time in all groups; high‐dose gabapentin was statistically superior but clinically similar to lorazepam (p = 0.009). During treatment, lorazepam‐treated participants had higher probabilities of drinking on the first day of dose decrease (day 2) and the second day off medication (day 6) compared to gabapentin‐treated participants (p = 0.0002). Post‐treatment, gabapentin‐treated participants had less probability of drinking during the follow‐up post‐treatment period (p = 0.2 for 900 mg and p = 0.3 for 1200 mg) compared to the lorazepam‐treated participants (p = 0.55). The gabapentin groups also had less craving, anxiety, and sedation compared to lorazepam. Conclusions: Gabapentin was well tolerated and effectively diminished the symptoms of alcohol withdrawal in our population especially at the higher target dose (1200 mg) used in this study. Gabapentin reduced the probability of drinking during alcohol withdrawal and in the immediate postwithdrawal week compared to lorazepam.     

Evaluating a cognitive model of ALDH2 and drinking behavior

Background: Despite evidence for genetic influences on alcohol use and alcohol‐related cognitions, genetic factors and endophenotypes are rarely incorporated in cognitive models of drinking behavior. This study evaluated a model of ALDH2 and drinking behavior stipulating cognitive factors and alcohol sensitivity as accounting for genetic influences on drinking outcomes. Methods: Participants were Asian‐American young adults (n = 171) who completed measures of alcohol cognitions (drinking motives, drinking refusal self‐efficacy, and alcohol expectancies), alcohol sensitivity, drinking behavior, and alcohol‐related problems as part of a prospective study. Structural equation modeling (SEM) evaluated a model of drinking behavior that stipulated indirect effects of ALDH2 on drinking outcomes through cognitive variables and alcohol sensitivity. Results: The full model provided an adequate fit to the observed data, with the measurement model explaining 63% of the variance in baseline heavy drinking and 50% of the variance in alcohol‐related problems at follow‐up. Associations of ALDH2 with cognitive factors and alcohol sensitivity were significant, whereas the association of ALDH2 with drinking was not significant with these factors included in the model. Mediation tests indicated significant indirect effects of ALDH2 through drinking motives, drinking refusal self‐efficacy, and alcohol sensitivity. Conclusions: Results are consistent with the perspective that genetic influences on drinking behavior can be partly explained by learning mechanisms and implicate cognitive factors as important for characterizing associations of ALDH2 with drinking.     

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.     

Long-Term Effects of Minimum Drinking Age Laws on Past-Year Alcohol and Drug Use Disorders

Background: Many studies have found that earlier drinking initiation predicts higher risk of later alcohol and substance use problems, but the causal relationship between age of initiation and later risk of substance use disorder remains unknown. Method: We use a “natural experiment” study design to compare the 12‐month prevalence of Diagnostic and Statistical Manual, Fourth Edition, alcohol and substance use disorders among adult subjects exposed to different minimum legal drinking age laws minimum legal drinking age in the 1970s and 1980s. The sample pools 33,869 respondents born in the United States 1948 to 1970, drawn from 2 nationally representative cross‐sectional surveys: the 1991 National Longitudinal Alcohol Epidemiological Survey (NLAES) and the 2001 National Epidemiological Study of Alcohol and Related Conditions. Analyses control for state and birth year fixed effects, age at assessment, alcohol taxes, and other demographic and social background factors. Results: Adults who had been legally allowed to purchase alcohol before age 21 were more likely to meet criteria for an alcohol use disorder [odds ratio (OR) 1.31, 95% confidence intervals (95% CI) 1.15 to 1.46, p < 0.0001] or another drug use disorder (OR 1.70, 95% CI 1.19 to 2.44, p = 0.003) within the past‐year, even among subjects in their 40s and 50s. There were no significant differences in effect estimates by respondent gender, black or Hispanic ethnicity, age, birth cohort, or self‐reported age of initiation of regular drinking; furthermore, the effect estimates were little changed by inclusion of age of initiation as a potential mediating variable in the multiple regression models. Conclusion: Exposure to a lower minimum legal purchase age was associated with a significantly higher risk of a past‐year alcohol or other substance use disorder, even among respondents in their 40s or 50s. However, this association does not seem to be explained by age of initiation of drinking, per se. Instead, it seems plausible that frequency or intensity of drinking in late adolescence may have long‐term effects on adult substance use patterns.     

Ten-year trends (1992 to 2002) in sociodemographic predictors and indicators of alcohol abuse and dependence among whites, blacks, and Hispanics in the United States

Background: The objective of this paper is to examine 10‐year trends (1992 to 2002) in the number and type of indicators of DSM‐IV abuse and dependence among whites, blacks, and Hispanics in the United States. Methods: Data are from the 1991 to 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES; n = 42,862) and the 2001 to 2002 National Epidemiologic Study on Alcohol and Related Conditions (NESARC; n = 43,093). Both surveys used multistage cluster sample procedures to select respondents 18 years of age and older from the U.S. household population. Results: Increases in the prevalence of alcohol abuse between 1992 and 2002 seem associated with a rise in the prevalence of the indicator for “hazardous use.” which usually means reports of driving after drinking. The decrease in dependence was not associated with changes in a particular indicator. In addition, both in 1992 and 2002, 12.3 to 15.4% of the men and 5.2 to 7.9% of the women were diagnostic “orphans.” These respondents reported 1 or 2 indicators of alcohol dependence as present. Conclusions: The observed trends in number and types of indicators of DSM‐IV alcohol abuse and dependence were probably triggered by a complex interplay between individuals’ volume and pattern of drinking and reactions from the drinkers’ social environment. The close association between hazardous use of alcohol and the prevalence of abuse deserves further discussion. A medical diagnostic category should not be so dependent on a criterion that may be influenced by social situations. It is necessary to understand more about diagnostic “orphans” to better design interventions to address their problems.     

The Effects of Fetal Alcohol Syndrome on Response Execution and Inhibition: An Event-Related Potential Study

Background: Both executive function deficits and slower processing speed are characteristic of children with fetal alcohol exposure, but the temporal dynamics of neural activity underlying cognitive processing deficits in fetal alcohol spectrum disorder have rarely been studied. To this end, event‐related potentials (ERPs) were used to examine the nature of alcohol‐related effects on response inhibition by identifying differences in neural activation during task performance. Methods: We recorded ERPs during a Go/No‐go response inhibition task in 2 groups of children in Cape Town, South Africa (M age = 11.7 years; range = 10 to 13)—one diagnosed with fetal alcohol syndrome (FAS) or partial FAS (FAS/PFAS; n = 7); the other, a control group whose mothers abstained or drank only minimally during pregnancy (n = 6). Children were instructed to press a “Go” response button to all letter stimuli presented except for the letter “X,” the “No‐go” stimulus, which occurred relatively infrequently. Results: Task performance accuracy and reaction time did not differ between groups, but differences emerged for 3 ERP components—P2, N2, and P3. The FAS/PFAS group showed a slower latency to peak P2, suggesting less efficient processing of visual information at a relatively early stage (～200 ms after stimulus onset). Moreover, controls showed a larger P2 amplitude to Go versus No‐go, indicating an early discrimination between conditions that was not seen in the FAS/PFAS group. Consistent with previous literature on tasks related to cognitive control, the control group showed a well‐defined, larger N2 to No‐go versus Go, which was not evident in the FAS/PFAS group. Both groups showed the expected larger P3 amplitude to No‐go versus Go, but this condition difference persisted in a late slow wave for the FAS/PFAS group, suggesting increased cognitive effort. Conclusions: The timing and amplitude differences in the ERP measures suggest that slower, less efficient processing characterizes the FAS/PFAS group during initial stimulus identification. Moreover, the exposed children showed less sharply defined components throughout the stimulus and response evaluation processes involved in successful response inhibition. Although both groups were able to inhibit their responses equally well, the level of neural activation in the children with FAS/PFAS was greater, suggesting more cognitive effort. The specific deficits in response inhibition processing at discrete stages of neural activation may have implications for understanding the nature of alcohol‐related deficits in other cognitive domains as well.     

Implicit and explicit alcohol cognitions and observed alcohol consumption: three studies in (semi)naturalistic drinking settings

Aims Dual‐process models imply that alcohol use is related to implicit as well as explicit cognitive processes. Few studies have tested whether both types of processes are related to ad libitum drinking. In a series of three studies, we tested whether both implicit and explicit alcohol‐related cognitions predicted the amount of alcohol consumed in an ad libitum (semi)naturalistic drinking situation. Design Two experimental studies used trained confederates (same‐sex peers) who consumed either alcoholic or non‐alcoholic beverages, while observing participants' drinking behaviour in a 30‐minute session. The third study involved observations of participants' alcohol use during a 45‐minute session in which participants spent time with five to seven friends. Setting A (semi)naturalistic drinking setting, a laboratory bar. Participants Participants were undergraduates recruited at Radboud University (study 1: n = 115; study 2: n = 121; study 3: n = 200). Measurements We used coding of drinking behaviour from observations, questionnaire data on positive alcohol expectancies and alcohol use patterns and implicit association tests to assess alcohol associations. Findings Implicit associations were not related to observed alcohol use, whereas explicit positive expectancies were related positively to observed alcohol use in study 1 and study 2. Conclusions Among undergraduate students in (semi)naturalistic drinking settings with peers, implicit alcohol‐related cognitions do not predict the amount of alcohol consumed.     

A Metric of Maternal Prenatal Risk Drinking Predicts Neurobehavioral Outcomes in Preschool Children

Background: Fetal Alcohol Spectrum Disorders (FASDs), including Fetal Alcohol Syndrome, continue to be high‐incidence developmental disorders. Detection of patterns of maternal drinking that place fetuses at risk for these disorders is critical to diagnosis, treatment, and prevention, but is challenging and often insufficient during pregnancy. Various screens and measures have been used to identify maternal risk drinking but their ability to predict child outcome has been inconsistent. This study hypothesized that a metric of fetal “at‐risk” alcohol exposure (ARAE) derived from several indicators of maternal self‐reported drinking would predict alcohol‐related neurobehavioral dysfunctions in children better than individual measures of maternal alcohol consumption alone. Methods: Self‐reported peri‐conceptional and repeated maternal drinking during pregnancy were assessed with semi‐structured interviews and standard screens, i.e., the CAGE, T‐ACE, and MAST, in a prospective sample of 75 African‐American mothers. Drinking volumes per beverage type were converted to standard quantity and frequency measures. From these individual measures and screening instruments, a simple dichotomous index of prenatal ARAE was defined and used to predict neurobehavioral outcomes in the 4‐ to 5‐year‐old offspring of these women. Study outcomes included IQ, attention, memory, visual‐motor integration, fine motor skill, and behavior. Statistical analyses controlled for demographic and other potential confounders. Results: The current “at‐risk” drinking metric identified over 62% of the mothers as drinking at risk levels—23% more than the selection criterion identified—and outperformed all individual quantity and frequency consumption measures, including averages of weekly alcohol use and “binge” alcohol exposures (assessed as intake per drinking occasion), as well as an estimate of the Maternal Substance Abuse Checklist ( Coles et al., 2000 ), in predicting prenatal alcohol‐related cognitive and behavioral dysfunction in 4‐ to 5‐year‐old children. Conclusions: A metric reflecting multiple indices of “at‐risk” maternal alcohol drinking in pregnancy had greater utility in predicting various prenatal alcohol‐related neurobehavioral dysfunction and deficits in children compared to individual measures of maternal self‐reported alcohol consumption or a previous maternal substance abuse index. Assessing fetal risk drinking in pregnant women was improved by including multiple indicators of both alcohol consumption and alcohol‐related consequences and, if appropriate practical applications are devised, may facilitate intervention by health care workers during pregnancy and potentially reduce the incidence or severity of FASDs.     

Alcohol Expectancies and Drinking Refusal Self‐Efficacy Mediate the Association of Impulsivity With Alcohol Misuse

Background: Recent work suggests that 2 biologically based traits convey risk for alcohol misuse: reward sensitivity/drive and (rash) impulsiveness. However, the cognitive mechanisms through which these traits convey risk are unclear. This study tested a model predicting that the risk conveyed by reward sensitivity is mediated by a learning bias for the reinforcing outcomes of alcohol consumption (i.e., positive alcohol expectancy). The model also proposed that the risk conveyed by rash impulsiveness (RI) is mediated by drinkers’ perceived ability to resist alcohol (i.e., drinking refusal self‐efficacy). Methods: Study 1 tested the model in a sample of young adults (n = 342). Study 2 tested the model in a sample of treatment‐seeking substance abusers (n = 121). All participants completed a battery of personality, cognitive, and alcohol use questionnaires and models were tested using structural equation modeling. Results: In both studies, the hypothesized model was found to provide a good fit to the data, and a better fit than alternative models. In both young adults and treatment‐seeking individuals, positive alcohol expectancy fully mediated the association between reward sensitivity and hazardous alcohol use. For treatment seekers, drinking refusal self‐efficacy fully mediated the association between RI and hazardous drinking. However, there was partial mediation in the young adult sample. Furthermore, neither trait was directly associated with the other cognitive mediator. Conclusions: The hypothesized model was confirmed on a large sample of young adults and replicated on a sample of treatment‐seeking substance abusers. Taken together, these findings shed further light on the mechanisms through which an impulsive temperament may convey risk for alcohol misuse.     

Severity of acute illness is associated with baseline readiness to change in medical intensive care unit patients with unhealthy alcohol use

Background: Unhealthy alcohol use predisposes to multiple conditions that frequently result in critical illness and is present in up to one‐third of patients admitted to a medical intensive care unit (ICU). We sought to determine the baseline readiness to change in medical ICU patients with unhealthy alcohol use and hypothesized that the severity of acute illness would be independently associated with higher scores on readiness to change scales. We further sought to determine whether this effect is modified by the severity of unhealthy alcohol use. Methods: We performed a cross‐sectional observational study of current regular drinkers in 3 medical ICUs. The Alcohol Use Disorders Identification Test was used to differentiate low‐risk and unhealthy alcohol use and further categorize patients into risky alcohol use or an alcohol use disorder. The severity of a patient’s acute illness was assessed by calculating the Acute Physiologic and Chronic Health Evaluation II (APACHE II) score at the time of admission to the medical ICU. Readiness to change was assessed using standardized questionnaires. Results: Of 101 medical ICU patients who were enrolled, 65 met the criteria for unhealthy alcohol use. The association between the severity of acute illness and readiness to change depended on the instrument used. A higher severity of illness measured by APACHE II score was an independent predictor of readiness to change as assessed by the Stages of Change Readiness and Treatment Eagerness Scale (Taking Action scale; p < 0.01). When a visual analog scale was used to assess readiness to change, there was a significant association with severity of acute illness (p < 0.01) that was modified by the severity of unhealthy alcohol use (p = 0.04 for interaction term). Conclusions: Medical ICU patients represent a population where brief interventions require further study. Studies of brief intervention should account for the severity of acute illness and the severity of unhealthy alcohol use as potential effect modifiers.     

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.     

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

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

Variation in genes encoding the neuroactive steroid synthetic enzymes 5α-reductase type 1 and 3α-reductase type 2 is associated with alcohol dependence

Background: Studies of alcohol effects in rodents and in vitro implicate endogenous neuroactive steroids as key mediators of alcohol effects at GABA_A receptors. We used a case‐control sample to test the association with alcohol dependence (AD) of single nucleotide polymorphisms in the genes encoding two key enzymes required for the generation of endogenous neuroactive steroids: 5α–reductase, type I (5α‐R), and 3α‐hydroxysteroid dehydrogenase, type 2 (3α‐HSD), both of which are expressed in human brain. Methods: We focused on markers previously associated with a biological phenotype. For 5α‐R, we examined the synonymous SRD5A1 exon 1 SNP rs248793, which has been associated with the ratio of dihydrotestosterone to testosterone. For 3α‐HSD, we examined the nonsynonymous AKR1C3 SNP rs12529 (H5Q), which has been associated with bladder cancer. The SNPs were genotyped in a sample of 1,083 non‐Hispanic Caucasians including 552 controls and 531 subjects with AD. Results: The minor allele for both SNPs was more common among controls than subjects with AD: SRD5A1 rs248793 C‐allele (χ²(1) = 7.6, p = 0.006) and AKR1C3 rs12529 G‐allele (χ²(1) = 14.6, p = 0.0001). There was also an interaction of these alleles such that the “protective” effect of the minor allele at each marker for AD was conditional on the genotype of the second marker. Conclusions: We found evidence of an association with AD of polymorphisms in two genes encoding neuroactive steroid biosynthetic enzymes, providing indirect evidence that neuroactive steroids are important mediators of alcohol effects in humans.     

Markers of oxidative stress and systemic vasoconstriction in pregnant women drinking > or =48 g of alcohol per day

Background: The precise pathway by which alcohol causes the characteristic features of fetal alcohol spectrum disorders is unknown. Proposed mechanisms for fetal injury from maternal alcohol use include cellular damage from oxidative stress and impaired fetal oxygenation related to maternal systemic vasoconstriction. Our objective was to compare the levels of urinary markers of oxidative stress and systemic vasoconstriction between women consuming large amounts of alcohol during pregnancy and women who did not drink alcohol during pregnancy. Methods: Pregnant women consuming ≥48 g alcohol per day (n = 29) on average and pregnant women who abstained from alcohol use (n = 39) were identified using detailed interviews and home visits. Random maternal urine specimens were collected. Urinary levels of the oxidative stress marker, 8‐isoprostane F2α, and of the vasoactive prostaglandin metabolites, 2,3‐dinor‐6‐keto‐prostaglandin F1α (a vasodilator) and 11‐dehydro‐thromboxane B2 (a vasoconstrictor), were measured using mass spectrometric methods. All analyte levels were corrected for urinary creatinine. Results: In crude analyses, there was no significant difference in 8‐isoprostane F2α between pregnant drinkers and nondrinkers (2.16 vs. 2.08 ng/mg creatinine, respectively, p = 0.87). There were no significant differences between the drinking and nondrinking groups in levels of 2,3‐dinor‐6‐keto‐prostaglandin F1α (1.03 vs. 1.17 ng/mg creatinine, repectively, p = 0.50), 11‐dehydro‐thromboxane B2 (0.72 vs. 0.59 ng/mg creatinine, respectively, p = 0.21), or the ratio of vasodilatory metabolite to vasoconstrictive metabolite (1.73 vs. 2.72, respectively, p = 0.14). Adjusting for maternal age, marital status, smoking, and gestational age at sampling did not substantially alter the results. Conclusion: Our results show no difference in levels of urinary eicosanoid markers of oxidative stress and systemic vasoconstriction between pregnant women who drink heavily and pregnant women who abstain. These findings speak against a role for maternal oxidative stress or systemic vasoconstriction in the pathogenesis of alcohol damage to the fetus.