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.     

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.     

Age at first drink and risk for alcoholism: a noncausal association

Prior research indicates risk for alcoholism is increased among individuals who begin to drink at an early age. We replicate and extend these findings, addressing causal and noncausal explanations for this association. Structured psychiatric interviews, including assessment of lifetime DSM-IV alcohol abuse and alcohol dependence (AD), were conducted with 8746 adult twins ascertained through a population-based twin registry. We found strong evidence for an association between early drinking onset and risk for AD, but less evidence for an association with alcohol abuse. The results of twin-pair analyses suggest that all of the association between early drinking and later AD is due to familial sources, which probably reflect both shared environmental and genetic factors. These results suggest the association between drinking onset and diagnosis is noncausal, and attempts to prevent the development of AD by delaying drinking onset are unlikely to be successful.     

A comparison of correlates of DSM-IV alcohol abuse or dependence among more than 400 sons of alcoholics and controls

BACKGROUND: Alcohol dependence and abuse are defined as separate disorders. However, relatively few data are available about whether the same characteristics predict both syndromes. METHODS: Complete data were available from the 15 year follow-up of 411 men who originally had been evaluated from a university population at about age 20. Both baseline data gathered prospectively and the retrospective ratings in six domains of life functioning were analyzed for their relationship to the development of alcohol abuse or dependence during the follow-up. RESULTS: Baseline characteristics of a family history of substance use disorders, the quantity and frequency of drinking, the history of alcohol-related problems, and the level of response to alcohol all predicted future alcohol abuse or dependence, but only an alcoholic second-degree relative or a first-degree drug-dependent family member differentially predicted dependence. Logistic regression analyses revealed that similar baseline characteristics combined to predict dependence and, separately, abuse. When the domains of functioning during the 15 years were included, positive alcohol expectancies, poor coping mechanisms, low level of social support, and drinking in the environment contributed to both dependence and abuse, although the relationship was stronger for dependence. CONCLUSIONS: The predictors and correlates of alcohol abuse and dependence in this group of men were similar. Further research in additional populations and on other drugs is needed to determine if the two syndromes overlap sufficiently to be combined.     

Alcoholism and Occupations: A Review and Analysis of 104 Occupations

A review of the many attempts to establish an association between occupations and alcoholism reveals that most do not deal with data about clinically defined alcoholism but instead use data about cirrhosis mortality, self-reported alcohol problems, and frequent and heavy drinking. The present study establishes an association between occupations and diagnoses of Alcohol Dependence Disorder and Alcohol Abuse Disorder, using data from a large population-based household interview study. Statistical adjustment using logistic methods reveals that apparent associations between occupations and alcohol-related disorders previously reported in the literature are due to characteristics of those employed in various occupations. The prevalence of alcohol dependence and abuse in two high risk industries, construction and transportation, is confirmed. More than one in four construction laborers and one in five skilled construction trades workers received a DIS/DSM-III diagnosis related to alcohol abuse. In the transportation industry one in six heavy truck drivers and material movers received an alcohol diagnosis. Analyses of the data from individuals currently employed and not employed in their occupation reveals reduction in risk for those who leave some occupations and increased risk for those who leave other occupations. Evidence is presented that employment in some occupations may be protective for Alcohol Dependence. The findings support the view that occupation may be associated with Alcohol Dependence and Alcohol Abuse independent of demographic variations. Previously proposed explanatory models for associations between occupations and alcohol problems are called into question because they do not take into account the demographic characteristics and employment status of workers.     

Nosological Comparisons of DSM-III-R and DSM-IV Alcohol Abuse and Dependence in a Clinical Facility:Comparison with the 1988 National Health Interview Survey Results

The purpose of this study was to compare DSM-III-R and proposed formulations of DSM-IV diagnoses of alcohol use disorders in a clinical sample with the same assessment methods used in a large national survey previously reported. Issues included the number of symptoms required for abuse and dependence diagnoses, the effects of requiring evidence of physiological dependence to make the dependence diagnosis (Option 1 vs. Option 2), whether to require a duration criterion, and the concept of alcohol abuse. The diagnostic criteria proposed in the 1991 DSM-IV options book were the criteria investigated in this study. Concordance between DSM-III-R and DSM-IV was closest when the form of DSM-IV used was most similar to DSM-III-R. The duration criterion had much less effect on a dependence diagnosis in this clinical sample than in the general population. DSM-IV Option 2 for alcohol dependence excluded a number of cases from the dependence diagnosis who received such a diagnosis under DSM-III-R and DSM-IV Option 1. Abuse continued to function as a residual category, especially noticeable under increasingly restrictive definitions of dependence, and was rare in both the clinical and general population sample. Implications of the findings for research and other purposes are discussed.     

Sex Differences in the Sources of Genetic Liability to Alcohol Abuse and Dependence in a Population-Based Sample of U.S. Twins

BACKGROUND: There are substantial sex differences in all levels of alcohol involvement among U.S. adults. The goal of this study was to test whether the magnitude and sources of genetic and environmental influences on liability for alcohol abuse and dependence differ for men and women. METHODS: Structured personal interviews were used to assess DSM-III-R- and DSM-IV-defined alcohol abuse and dependence among 5091 male and 4168 female twins (including 1546 identical, 1128 same-sex fraternal, and 1423 opposite-sex pairs) born in Virginia between 1934 and 1974. Twin correlations were analyzed using structural equation modeling. RESULTS: The magnitude of twin-pair resemblance was similar across several definitions of alcoholism and was substantially higher among identical than fraternal pairs. The proportion of population variation in liability attributed to genetic factors was substantial among both women (55-66%) and men (51-56%), and we found little evidence of a role of environmental factors shared by family members. In all definitions studied, we could reject a model that the genetic sources of liability in the two sexes overlap completely. CONCLUSION: In this first population-based study of alcoholism among male and female twins from the U.S., we found that genetic factors play a major role in the development of alcoholism in both sexes, that the magnitudes of genetic influence were equally high for men and women, and that the genetic sources of vulnerability are partially, but not completely, overlapping in men and women.     

Alcohol dependence and abuse diagnoses: concurrent validity in a nationally representative sample

The Alcohol Dependence Syndrome concept has had a widespread influence on the major nosological classification systems, most recently with its operationalization as DSM-IV alcohol dependence. Although many studies have provided evidence of the validity of the Alcohol Dependence Syndrome in clinical samples, little validation work has been conducted in general population samples on DSM-IV alcohol dependence or the distinction of DSM-IV alcohol dependence from DSM-IV alcohol abuse. We therefore examined the cross-sectional validity of DSM-IV alcohol dependence and abuse in 27,616 household residents who participated in a 1992 national survey on alcohol use disorders. Validity was investigated by testing the association of a set of five "criterion" variables, external to the alcohol diagnostic criteria, with dependence and abuse diagnoses. Results indicated that dependence diagnoses were significantly associated with all criterion variables when compared with those with no diagnosis and also when compared with alcohol abuse. This supported the separation of dependence from abuse. Abuse diagnoses were associated with some, but not all, criterion variables when compared with subjects with no diagnosis. This report replicates many aspects of a similar investigation in a community sample of household residents. Implications for the next steps in research are discussed.     

Occupational Stress and the Risk of Alcohol Abuse and Dependence

Using prospective data, we examined the relationship between occupational stress and risk for alcohol disorders. Consistent with the Demand/Control model for psychosocial work environments, we hypothesized that individuals working in high-strain occupations (jobs with high demands and low control) would be at increased risk for alcohol abuse-dependence relative to those in low-strain occupations (jobs with low demands and high control). We classified high occupational strain into two categories: (1) jobs with high psychological demands and low control, and (2) those with high physical demands and low control. A total of 18,571 study subjects were selected in 1980–1984 by taking probability samples of adult household residents at five sites of the Epidemiologic Catchment Area Program. At baseline, participants completed standardized interviews that measured sociode-mographic variables and assessed whether they had met diagnostic criteria for currently or formerly active alcohol abuse-dependence syndromes. The interviews were readministered 1 year later to identify cases among the participants. Subjects were sorted into risk sets by age and residence census tract₁ and persons with a previous history of alcohol abuse or dependence, as well as those who were over 64 years or had no history of full-time employment, were excluded. Among the 507 participants included in the risk sets, there were 126 incident cases of alcohol abuse-dependence and 381 age and residence-matched noncases. Relative to low-strain employment, men were found to be 27.5 times more likely to develop alcohol abuse-dependence if they had been employed in a high-strain job classified as having high psychological demands and low control (p= 0.008), and 3.4 times at higher risk for an alcohol disorder if they were employed in high-strain jobs with high physical demands and low control (p= 0.03). No appreciable risk was found for women in any of the high-strain job categories. The results highlight occupational stress as a potential risk factor for alcohol abuse and dependence, and add to the growing body of literature on relationships between psychosocial work environment and disease states. If confirmed in other studies, these findings identify potential sources of preventive strategies for alcohol disorders.     

Epidemiology of Alcohol Abuse and Dependence in Rural Chinese Men

Background:  Several national and regional epidemiological studies in China have reported increases in the prevalence of alcohol use disorders over the past 3 decades.
Methods:  This cross-sectional study conducted in 2007 identified 11,884 male subjects aged 18 to 60 years using multi-stage randomized cluster sampling methods in 2 rural communities in China and interviewed 9,866 of them. Current and lifetime alcohol use disorders were assessed with a semi-structured diagnostic interview.
Results:  The age-standardized prevalence of current (lifetime) alcohol abuse and alcohol dependence in Hunan were 1.8% (4.8%) and 4.7% (8.6%) respectively, and those in Henan were 7.6% (11.8%) and 8.7% (10.8%). Higher age (55 to 60) and lower education were risk factors for alcohol dependence in Hunan while middle age (35 to 44), currently married, and higher education and higher income were risk factors in Henan.
Conclusions:  Alcohol abuse and dependence are no longer uncommon disorders among rural men in China. Unlike most western reports, alcohol dependence shows higher prevalence than abuse. There are significant differences in the prevalence of alcohol use disorders and the socio-demographic profile of affected individuals in the 2 different regions of the country.     

Voices of the Afflicted

Over the past 10 years, I have been privileged to conduct educational forums for audiences containing many recovering alcoholics or otherwise chemically dependent persons. In these forums about the addictive diseases and their treatment and research possibilities, significant interaction with the audience members occurs. During these interactions, certain anecdotal phenomena seem to predominate. The repetitive nature of these reports suggests the need for systematic investigation. As with editorial comments in major medical journals, observed phenomena and unanswered questions from those afflicted can be valuable in the generation of testable hypotheses. Perhaps the ideas presented herein will be useful in the development of future research on alcohol abuse and alcohol dependence.     

1994 Draft DSM-IV Criteria for Alcohol Use Disorders: Comparison to DSM-III-R and Implications

In 1994, DSM-IV will be published, with new criteria for alcohol abuse and dependence. Implications of the changes in criteria for alcohol use disorders were investigated by comparing the diagnoses made by the DSM-IV criteria and DSM-III-R criteria. The study was conducted in a sample of 424 patients in an inpatient alcohol rehabilitation unit in the New York metropolitan area. DSM-III-R and DSM-IV criteria showed similar results and high agreement for any alcohol use disorder (abuse and dependence combined). Alcohol dependence was also consistently diagnosed with DSM-III-R and DSM-IV criteria. Agreement between DSM-III-R and DSM-IV abuse diagnoses was very low. Compared with DSM-III-R, DSM-IV classified over three times as many patients as alcohol abusers, although those with alcohol dependence still overwhelmingly dominated the sample. With some fluctuations, the results were stable over Black, Hispanic, and White subgroups of patients. The direction of the findings was consistent with results from a national general population survey in that the prevalence of alcohol abuse increased in both studies. However, the clinical results alone would not have suggested the marked changes in relative prevalence of abuse and dependence that occurred in the general population when DSM-IV criteria were used in place of DSM-III-R. Research on diagnostic criteria limited to patient samples omits important information on the implications of changing aspects of the diagnostic criteria. The need for a coherent theory of alcohol abuse is highlighted.     

Parallels to early onset alcohol use in the relationship of early onset smoking with drug use and DSM-IV drug and depressive disorders: findings from the National Longitudinal Epidemiologic Survey

This paper endeavored to determine (1) if early onset of regular tobacco use is as predictive of drug use and depressive disorders as it is of alcohol use disorders; and (2) if a biological commonality, as measured by a family history of alcoholism and both early onset and severity of disease, among all three disorders can be evidenced in a large nationally representative sample. Prevalences of lifetime drug use, drug abuse and dependence, and major depressive disorders, as well as indices of their severity, were compared among smoking groups defined by age at onset of regular tobacco use and among nonsmokers. Linear logistic regression analyses, controlling for important covariates, including a family history positive for alcoholism, were conducted to assess the relationship between age at smoking onset and drug use, abuse and dependence, as well as depressive disorders. Both objectives were met. Moreover, results suggest that smoking may play an equally, if not even more, insidious role than drinking in the use and development of dependence on illicit substances and depression.     

Comparing the Diagnostic Accuracy of Carbohydrate-Deficient Transferrin, γ-Glutamyltransferase, and Mean Cell Volume in a General Practice Population

In certain populations, the biological alcohol marker carbohydrate-deficient transferrin (CDT) is known to have a high diagnostic accuracy. The aim of this study was to compare the diagnostic accuracy of CDT, gamma-glutamyltransferase (gamma-GT), and mean cell volume (MCV) in a general practice population; more specifically, to ascertain whether CDT is a better tool than gamma-GT and MCV for (early) recognition of excessive alcohol use. To represent the general practice situation as realistically as possible, three different drinking patterns are defined: irregular excessive, regular excessive, and very excessive. From a sample of 524 men from seven general practices, sensitivity, specificity, and predictive values of the three markers for the three drinking patterns were compared, and receiver-operating characteristic analysis was used to compare differences between the markers. The results indicate that drinking patterns do influence the (difference in) diagnostic accuracy. CDT has a higher diagnostic accuracy for all three drinking patterns than gamma-GT and higher predictive values for hazardous [(ir)regular excessive] drinking patterns than MCV. However, receiver-operating characteristic analyses failed to demonstrate a significant difference between these patterns. It is concluded that the performance of all tests is too low to be useful for screening procedures in a general population; however, some tests may be useful for case finding. CDT seems to be the best alcohol marker available, although the difference between CDT and MCV is small.     

Voices of the Afflicted

Over the past 10 years, I have been privileged to conduct educational forums for audiences containing many recovering alcoholics or otherwise chemically dependent persons. In these forums about the addictive diseases and their treatment and research possibilities, significant interaction with the audience members occurs. During these interactions, certain anecdotal phenomena seem to predominate. The repetitive nature of these reports suggests the need for systematic investigation. As with editorial comments in major medical journals, observed phenomena and unanswered questions from those afflicted can be valuable in the generation of testable hypotheses. Perhaps the ideas presented herein will be useful in the development of future research on alcohol abuse and alcohol dependence.     

Voice of the Victims

Over the past 10 years, I have been privileged to conduct educational forums for audiences containing many recovering alcoholics or otherwise chemically dependent persons. In these forums about the addictive diseases and their treatment and research possibilities, significant interaction with the audience members occurs. During these interactions, certain anecdotal phenomena seem to predominate. The repetitive nature of these reports suggests the need for systematic investigation. As with editorial comments in major medical journals, observed phenomena and unanswered questions from the victims can be valuable in the generation of testable hypotheses. Perhaps the ideas presented herein will be useful in the development of future research on alcohol abuse and alcoholism.     

Screening for Microalbuminuria in Type 2 Diabetic Patients: the Evaluation of a Dipstick Test in General Practice

To evaluate the Micral test, a semiquantitative dipstick test, in a general practice setting, 317 Type 2 diabetic patients completed a screening for microalbuminuria by means of the Micral test as well as immuno-nephelometry with the Disc 120 immuno-nephelometer (Hyland, Nivelles, Belgium). Data were collected in 10 general practices performing the Nijmegen Monitoring Project. At a regular check-up each Type 2 diabetic patient was asked to collect first morning urine samples on three consecutive days. The sensitivity of the Micral test was 67 %, the specificity 93 %. Between the practices the sensitivity ranged from 58 % to 81 %, the specificity from 87 % to 95 %. Microalbuminuria, defined as a mean urine albumin concentration ≥ 20 mg l^?1 by nephelometry on three consecutive days, was found in 66 patients (21 %). The first Micral test correctly picked out these patients with microalbuminuria in 70 % of the cases and in 90 % those patients without microalbuminuria. The diagnostic performance of the Micral test was further proved by a Receiver Operating Characteristic (ROC) curve. The Area Under the Curve (AUC) of the Micral test was 0.84 (95 % Cl 0.78–0.90). Micral test results of 0 and 10 should be regarded as negative.