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

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

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

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

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.     

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.     

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.     

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.     

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

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

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.     

Gender differences in the performance of a computerized version of the alcohol use disorders identification test in subcritically injured patients who are admitted to the emergency department

OBJECTIVE: The Alcohol Use Disorder Identification Test (AUDIT) has been recommended as a screening tool to detect patients who are appropriate candidates for brief, preventive alcohol interventions. Lower AUDIT cutoff scores have been proposed for women; however, the appropriate value remains unknown. The primary purpose of this study was to determine the optimal AUDIT cutpoint for detecting alcohol problems in subcritically injured male and female patients who are treated in the emergency department (ED). An additional purpose of the study was to determine whether computerized screening for alcohol problems is feasible in this setting. METHODS: The study was performed in the ED of a large, urban university teaching hospital. During an 8-month period, 1205 male and 722 female injured patients were screened using an interactive computerized lifestyle assessment that included the AUDIT as an embedded component. World Health Organization criteria were used to define alcohol dependence and harmful drinking. World Health Organization criteria for excessive consumption were used to define high-risk drinking. The ability of the AUDIT to classify appropriately male and female patients as having one of these three conditions was the primary outcome measure. RESULTS: Criteria for any alcohol use disorder were present in 17.5% of men and 6.8% of women. The overall accuracy of the AUDIT was good to excellent. At a specificity >0.80, sensitivity was 0.75 for men using a cutoff of 8 points and 0.84 for women using a cutoff of 5 points. Eighty-five percent of patients completed computerized screening without the need for additional help. CONCLUSIONS: Different AUDIT scoring thresholds for men and women are required to achieve comparable sensitivity and specificity when using the AUDIT to screen injured patients in the ED. Computerized AUDIT administration is feasible and may help to overcome time limitations that may compromise screening in this busy clinical environment.     

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.     

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.     

Self-reported alcohol use versus phosphatidylethanol in behavioral trials: A study of people living with HIV in Tshwane,South Africa

Background

Accurately quantifying alcohol use among persons with HIV (PWH) is important for validly assessing the efficacy of alcohol reduction interventions.

Methods

We used data from a randomized controlled trial of an intervention to reduce alcohol use among PWH who were receiving antiretroviral therapy in Tshwane, South Africa. We calculated agreement between self-reported hazardous alcohol use measured by the Alcohol Use Disorders Identification Test (AUDIT; score ≥8) and AUDIT-Consumption (AUDIT-C; score ≥3 for females and ≥4 for males), heavy episodic drinking (HED) in the past 30 days, and heavy drinking in the past 7 days with a gold standard biomarker--phosphatidylethanol (PEth) level (≥50 ng/mL)--among 309 participants. We used multiple logistic regression to assess whether underreporting of hazardous drinking (AUDIT-C vs. PEth) differed by sex, study arm, and assessment time point.

Results

Participants' mean age was 40.6 years, 43% were males, and 48% were in the intervention arm. At 6 months, 51% had PEth ≥50 ng/mL, 38% and 76% had scores indicative of hazardous drinking on the AUDIT and AUDIT-C, respectively, 11% reported past 30-day HED, and 13% reported past 7-day heavy drinking. At 6 months, there was low agreement between AUDIT-C scores and past 7-day heavy drinking relative to PEth ≥50 (sensitivities of 83% and 20% and negative predictive values of 62% and 51%, respectively). Underreporting of hazardous drinking at 6 months was associated with sex (OR = 3.504. 95% CI: 1.080 to 11.364), with odds of underreporting being greater for females.

Conclusions

Steps should be taken to decrease underreporting of alcohol use in clinical trials.     

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.     

The alcohol use disorders identification test: an update of research findings

BACKGROUND: The Alcohol Use Disorders Identification Test (AUDIT) has been extensively researched to determine its capability to accurately and practically screen for alcohol problems. METHODS: During the 5 years since our previous review of the literature, a large number of additional studies have been published on the AUDIT, abbreviated versions of it, its psychometric properties, and the applicability of the AUDIT for a diverse array of populations. The current article summarizes new findings and integrates them with results of previous research. It also suggests some issues that we believe are particularly in need of further study. RESULTS: A growing body of research evidence supports the criterion validity of English version of the AUDIT as a screen for alcohol dependence as well as for less severe alcohol problems. Nevertheless, the cut-points for effective detection of hazardous drinking as well as identification of alcohol dependence or harmful use in women need to be lowered from the originally recommended value of 8 points. The AUDIT-C, the most popular short version of the AUDIT consisting solely of its 3 consumption items, is approximately equal in accuracy to the full AUDIT. Psychometric properties of the AUDIT, such as test-retest reliability and internal consistency, are quite favorable. Continued research is urged to establish the psychometric properties of non-English versions of the AUDIT, use of the AUDIT with adolescents and with older adults, and selective inclusion of alcohol biomarkers with the AUDIT in some instances. CONCLUSIONS: Research continues to support use of the AUDIT as a means of screening for the spectrum of alcohol use disorders in various settings and with diverse populations.     

The CAGE as a measure of hazardous drinking in the homeless

The aim of this study was to test the validity of the CAGE questions as a measure of severe drinking in subjects at drop-in centers for the homeless, using biological markers of acute liver reaction to alcohol as the "gold standard." A sample of homeless men and women in Copenhagen were invited to participate in a study of health problems. Subjects were interviewed and blood samples were taken and screened for indicators of liver dysfunction (gamma-glutamyltransferase [gammaGT], mean corpuscular volume [MCV], alanine aminotransferase [ALAT], and alkaline phosphatase [Alpase]), and hepatitis C [HCV]. Scores on CAGE correlated strongly with years of heavy drinking (rho = 0.43, p < 0.001), and while years of drinking did not correlate with biomarkers after controlling for multiple hypothesis testing, CAGE correlated with gammaGT, Alpase and ALAT, but not MCV. The correlations held even among those without HCV, but subjects with HCV + and CAGE > 1 had quite extreme values on liver markers. Findings suggested that the CAGE was able to identify homeless drinkers whose drinking was significantly associated with increases in biomarkers associated with heavy drinking.     

The validity of the CAGE scale to screen for heavy drinking and drinking problems in a general population survey

Background. The CAGE scale is a short test developed in the 1970s to screen for alcoholism or covert drinking problems. The reliability and validity of the scale has been demonstrated in the majority of studies conducted in clinical settings, but the validity of the scale in general population surveys has not yet been shown conclusively. Aims. The goal of this study was to assess the criterion validity of the CAGE scale in a general population survey. Method. Data from a large general health survey conducted in 1992 in the province of Quebec (Canada) (N=23 564) were used to define various measures of heavy drinking and drinking problems and to calculate, for male and female drinkers separately, standard measures of sensitivity, specificity and positive predictive value at different cutoff scores on the CAGE. Findings. With respect to both male and female drinkers, with all operational definitions of heavy drinking and useful cutoff scores on the CAGE, the scale was shown to be unable to discriminate between heavy drinkers and non-heavy drinkers. Prevalence of drinking problems among CAGE positive drinkers was also very low. Conclusion. These results do not support the use of the CAGE as a screening tool for heavy drinking and drinking problems in a general population survey or as a tool to estimate the prevalence of drinking problems in the 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.     

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.     

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.     

Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population

BACKGROUND: The three consumption questions from the Alcohol Use Disorders Identification Test (AUDIT-C) are increasingly used as a screener for alcohol use disorders (AUDs) and risk drinking. METHODS: In a representative sample of US adults 18 years of age and older, AUDIT-C scores (derived from consumption questions embedded in a large national survey) were used to estimate sensitivity, specificity, and areas under receiver operator characteristic curves (AUROCs) for alcohol dependence, any AUD, and risk drinking. AUDs were defined according to DSM-IV criteria. For men, risk drinking was defined as consuming >14 drinks per week or >4 drinks in a single day at least once a month; for women, the weekly and daily limits were >7 drinks and >3 drinks, respectively. The derived AUDIT-C was evaluated among past-year drinkers (n = 26,946), within the total population (n = 43,093), in groups defined by age, sex, and race/ethnicity, and among pregnant women, persons attending an emergency room, and college students. RESULTS: For past-year drinkers, the AUROCs for the derived AUDIT-C were 0.887 for alcohol dependence, 0.860 for any AUD, and 0.966 for risk drinking. Scores were higher in the total population, 0.931, 0.917, and 0.981, respectively. The derived AUDIT-C performed slightly better in screening for dependence among women than men. Screening for risk drinking was better among men, probably because the third AUDIT-C question directly mirrors one of the definitions of risk drinking for men but not for women. Performance in pregnant women, past-year emergency room patients, and college students was on a par with performance in the general population. CONCLUSIONS: The derived AUDIT-C performs well in screening for AUDs and risk drinking. The use of variable cut points for men and women improves its sensitivity and specificity. Validation in a realistic screening situation, in which the AUDIT-C questions are asked as stand-alone and not embedded items, is a critical future step.