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.     

Reactivity to alcohol assessment measures: an experimental test

Aims   Previous research has suggested that alcohol screening and assessment may affect drinking.
Design   This study was a randomized test of reactivity to alcohol assessment questionnaires among a group of heavy drinking college students.
Setting and participants   A total of 147 university students completed a screening questionnaire and were randomized to either immediate assessment or delayed assessment. The immediate assessment group completed a set of drinking questionnaires at baseline, 3, 6 and 12 months, while the delayed assessment group completed questionnaires only at 12 months.
Measurements   Primary outcomes included overall volume of drinking, risky drinking and use of risk reduction behaviors.
Findings   We found a significant effect of assessment on measures of risky drinking and risk reduction behaviors, but not on overall volume of drinking. Specifically, at 12 months, participants who had previously completed drinking assessments had a lower peak blood alcohol concentration (BAC) ( d  = −0.373), were more likely to report a low score on the Alcohol Use Disorders Identification Test (AUDIT; odds ratio = 2.55) and tended to use more strategies to moderate their alcohol consumption ( d  = 0.352). Risk reduction behaviors that were affected tended to be those that limited alcohol consumption, rather than those that minimized consequences.
Conclusions   These results may have implications for the development of brief interventions.     

Documentation of alcohol use in hospital records of newly diagnosed cancer patients: a population-based study

Alcohol use has been associated with increased risk and poorer prognosis of various types of cancer, but the extent of actual screening for alcohol use in hospitalized cancer patients has received limited attention. In a random sample of 618 Connecticut patients diagnosed in 2002 with invasive cancer at age 20 + years, ascertained from a population-based registry, some information on usual frequency of drinking was found in hospital records for 478 (77.3%), but 143 (57.2%) of the 250 current drinkers were poorly described (e.g., "social," "occasional"). Alcohol use disorders were rarely mentioned. Gamma glutamyl transpeptidase was found for only 21 (3.4%). Mean corpuscular volume (MCV) was found for 434 (70.2%) and was associated with heavier drinking, independent of other predictors of MCV. Better screening is needed for all hospitalized cancer patients, to plan for interventions and conduct follow-up studies of prognosis.     

Documentation of Alcohol Use in Hospital Records of Newly Diagnosed Cancer Patients: A Population-Based Study

Alcohol use has been associated with increased risk and poorer prognosis of various types of cancer, but the extent of actual screening for alcohol use in hospitalized cancer patients has received limited attention. In a random sample of 618 Connecticut patients diagnosed in 2002 with invasive cancer at age 20 + years, ascertained from a population-based registry, some information on usual frequency of drinking was found in hospital records for 478 (77.3%), but 143 (57.2%) of the 250 current drinkers were poorly described (e.g., “social,” “occasional”). Alcohol use disorders were rarely mentioned. Gamma glutamyl transpeptidase was found for only 21 (3.4%). Mean corpuscular volume (MCV) was found for 434 (70.2%) and was associated with heavier drinking, independent of other predictors of MCV. Better screening is needed for all hospitalized cancer patients, to plan for interventions and conduct follow-up studies of prognosis.     

Alcohol and the Cardiovascular System

Cardiovascular damage associated with alcohol abuse is predominantly seen with persistent heavy drinking. Occasionally nutritional deficiencies or congeners in alcoholic beverages may cause cardiac disease. Alcohol use is associated with other changes in lifestyle, especially smoking, which may also contribute to the associations between heavy drinking and cardiovascular disease. Alcohol excess is associated with hypertension, heart muscle disease and arrhythmias. Moderate drinking may reduce cardiovascular mortality compared to heavy drinking or abstension, but this is still controversial. Consumption of small amounts of alcohol in patients with angina causes temporary impairment of heart function. Diagnostic awareness of alcohol excess in cardiovascular disease needs to be increased and improvements in screening may be of assistance. The foetal alcohol syndrome includes cardiac malformations and requires greater efforts in prevention.     

Excessive alcohol consumption and hypertension: clinical implications of current research

Substantial evidence demonstrates that: 1) heavy alcohol consumption (three or more standard drinks per day) is associated with and predictive of hypertension; 2) reduction in alcohol consumption is associated with a significant dose-dependent lowering of mean systolic and diastolic blood pressure; and 3) physician advice can reduce heavy drinking in hypertensive patients. These findings suggest that the routine evaluation of alcohol consumption in hypertensive patients is warranted. The Alcohol Use Disorders Identification Test-C (AUDIT-C), a brief, three-question screening test, is useful in this regard. Alcohol biomarkers can also play a role in detecting and monitoring heavy drinking in hypertensive patients whose self-reports on the AUDIT-C are suspect. Carbohydrate-deficient transferrin, a new alcohol biomarker with high specificity, can provide objective data for feedback and counseling. A routine search for excessive use of alcohol, along with brief interventions and monitoring, can have a major impact on reducing the prevalence of hypertension in the general population.     

Performance of screening instruments for alcohol problems in the ER: a comparison of Mexican-Americans and Mexicans in Mexico

The performance of standard screening instruments and alternate measures against ICD-10 (International Classification of Diseases, 10th revision) and DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th revision) criteria for alcohol dependence and separately for harmful drinking/abuse were compared between probability samples of 1511 emergency room (ER) patients from three hospitals in Pachuca, Mexico, and 586 Mexican-American ER patients in Santa Clara County, California. Sensitivity was highest for the Alcohol Use Disorders Identification Test (AUDIT), TWEAK, and Rapid Alcohol Problems Screen (RAPS) for alcohol dependence; sensitivity was highest for holding five or more drinks for harmful drinking/abuse in both samples. All instruments performed better for alcohol dependence than for abuse/harmful drinking. Arrests for drinking and driving performed better in Santa Clara than in Pachuca, while a positive Breathalyzer reading and reporting drinking prior to the event performed better in Pachuca; both were significantly more sensitive among the injured compared to the noninjured in Pachuca. The data suggest that instrument performance may be similar between those in Pachuca and those in the low acculturation group in Santa Clara, relative to those scoring higher on acculturation. While standard screening instruments appear to work reasonably well in both samples for alcohol dependence, variation across gender, injury, and acculturation subgroups suggests attention should be given to choosing the "best" instrument.     

Substance use, injury, and risk-taking dispositions in the general population

Alcohol consumption has been found to be associated with injury occurrence and with risk-taking dispositions, and these dispositions, themselves, have been found to be associated with injury. Few studies have analyzed both alcohol consumption and risk-taking dispositions, or illicit drug use, on risk of injury across all types of injuries. Data on risk perception, risk-taking/impulsivity, sensation seeking, alcohol and drug use, demographic characteristics, and injury in the last year are reported from the 1995 National Alcohol Survey of 4925 respondents living in households in the 48 contiguous states. Moderate drinking, alcohol treatment, drug use, simultaneous use of alcohol and drugs, and risk-taking dispositions were all positively associated with reporting an injury. In multiple logistic regression, only risk-taking dispositions maintained significance when other variables were controlled. In separate regressions by ethnicity, risk-taking dispositions were significant predictors of injury for whites, whereas none of the variables were significant for blacks or Hispanics. Data suggest that risk-taking dispositions may be more important predictors of injury than either drinking or drug use variables, but this may vary by ethnicity. Risk-taking disposition may influence the effectiveness of strategies to reduce alcohol-related injuries; future research is important, therefore, for informing intervention and prevention efforts.     

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.     

Really underage drinkers: alcohol use among elementary students

Despite the current societal concern with underage drinking, little attention has been paid to alcohol use within the preadolescent population. This article presents the proceedings of a symposium held at the 2003 Research Society on Alcoholism meeting in Fort Lauderdale, Florida, that was organized and chaired by John E. Donovan. The intent of the symposium was to kick start research on alcohol use among elementary school children by reviewing what is known regarding drinking in childhood. Presentations included (1) The Epidemiology of Children's Alcohol Use, by John E. Donovan; (2) The Validity of Children's Self-Reports of Alcohol Use, by Sharon L. Leech; (3) Predicting Onset of Drinking From Behavior at Three Years of Age: Influence of Early Child Expectancies and Parental Alcohol Involvement Upon Early First Use, by Robert A. Zucker; and (4) Parent, Peer, and Child Risk Factors for Alcohol Use in Two Cohorts of Elementary School Children, by Carol J. Loveland-Cherry. Presentations indicated the need for better nationwide surveillance of children's experience with alcohol; suggested that children's reports of their use of alcohol tend to be reliable and valid; supported children's alcohol use schemas and parental drinking and alcoholism at child age three as independent predictors of early onset drinking; and showed that onset of drinking before fourth or fifth grade, peer pressure, and parental norms and monitoring predict elementary student alcohol use and misuse.     

Alcohol control policies and alcohol consumption by youth: a multi-national study

Aims The study examined relationships between alcohol control policies and adolescent alcohol use in 26 countries. Design Cross‐sectional analyses of alcohol policy ratings based on the Alcohol Policy Index (API), per capita consumption and national adolescent survey data. Setting Data are from 26 countries. Participants Adolescents (aged 15–17 years) who participated in the 2003 European School Survey Project on Alcohol and Other Drugs (ESPAD) or national secondary school surveys in Spain, Canada, Australia, New Zealand and the United States. Measurements Alcohol control policy ratings based on the API; prevalence of alcohol use, heavy drinking and first drink by age 13 based on national secondary school surveys; per capita alcohol consumption for each country in 2003. Analysis Correlational and linear regression analyses were conducted to examine relationships between alcohol control policy ratings and past 30‐day prevalence of adolescent alcohol use, heavy drinking and having first drink by age 13. Per capita consumption of alcohol was included as a covariate in regression analyses. Findings More comprehensive API ratings and alcohol availability and advertising control ratings were related inversely to the past 30‐day prevalence of alcohol use and prevalence rates for drinking three to five times and six or more times in the past 30 days. Alcohol advertising control was also related inversely to the prevalence of past 30‐day heavy drinking and having first drink by age 13. Most of the relationships between API, alcohol availability and advertising control and drinking prevalence rates were attenuated and no longer statistically significant when controlling for per capita consumption in regression analyses, suggesting that alcohol use in the general population may confound or mediate observed relationships between alcohol control policies and youth alcohol consumption. Several of the inverse relationships remained statistically significant when controlling for per capita consumption. Conclusions More comprehensive and stringent alcohol control policies, particularly policies affecting alcohol availability and marketing, are associated with lower prevalence and frequency of adolescent alcohol consumption and age of first alcohol use.     

Performance of Screening Instruments for Alcohol Problems in the ER: A Comparison of Mexican- Americans and Mexicans in Mexico*

The performance of standard screening instruments and alternate measures against ICD-10 (International Classification of Diseases, 10th revision) and DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th revision) criteria for alcohol dependence and separately for harmful drinking/abuse were compared between probability samples of 1511 emergency room (ER) patients from three hospitals in Pachuca, Mexico, and 586 Mexican-American ER patients in Santa Clara County, California. Sensitivity was highest for the Alcohol Use Disorders Identification Test (AUDIT), TWEAK, and Rapid Alcohol Problems Screen (RAPS) for alcohol dependence; sensitivity was highest for holding five or more drinks for harmful drinking/abuse in both samples. All instruments performed better for alcohol dependence than for abuse/harmful drinking. Arrests for drinking and driving performed better in Santa Clara than in Pachuca, while a positive Breathalyzer reading and reporting drinking prior to the event performed better in Pachuca; both were significantly more sensitive among the injured compared to the noninjured in Pachuca. The data suggest that instrument performance may be similar between those in Pachuca and those in the low acculturation group in Santa Clara, relative to those scoring higher on acculturation. While standard screening instruments appear to work reasonably well in both samples for alcohol dependence, variation across gender, injury, and acculturation subgroups suggests attention should be given to choosing the “best” instrument.     

Alcohol abuse and dependence in Latinos living in the United States: validation of the CAGE (4M) questions

BACKGROUND: Brief alcoholism screening questionnaires have not been adequately studied in the rapidly growing Latino population living in the United States. OBJECTIVE: To assess (1) the prevalence of alcoholism and (2) the performance of 2 alcohol screening instruments in Latinos. SUBJECTS AND METHODS: We performed a cross-sectional interview study in an urban teaching hospital-based primary care practice. Consecutive self-identified Latino subjects provided informed consent. All subjects were interviewed in English or Spanish using 2 alcoholism screening tools, the CAGE (or the Spanish version, the 4M), and the Alcohol Use Disorders Identification Test, and a criterion standard for the diagnosis of alcohol abuse and dependence, the Composite International Diagnostic Interview. RESULTS: Of 210 subjects interviewed, 36% had a lifetime diagnosis of alcohol abuse or dependence by the criterion standard. Thirty-one percent were currently drinking hazardous amounts of alcohol. A CAGE (4M) score of 1 or more was 92% sensitive and 74% specific, and a score of 2 or more was 80% sensitive and 93% specific for a lifetime diagnosis of alcohol abuse or dependency. CAGE (4M) scores of 0, 2, 3, and 4 were associated with likelihood ratios (0.1, 4.8, 18.5, and 36.8, respectively) that resulted in substantial changes from pretest (36%) to posttest probability (to 6%, 73%, 91%, and 95%, respectively) of a diagnosis of alcohol abuse or dependency. At the standard cutoff point, the Alcohol Use Disorders Identification Test detected only 51% of subjects with alcohol disorders. CONCLUSIONS: In Latinos in primary care settings, alcohol abuse and dependence are common and the CAGE (4M) is a brief, valid, screening tool for detecting alcohol use disorders.     

A Review of Research on the Alcohol Use Disorders Identification Test (AUDIT)

Research on the core version of the Alcohol Use Disorders Identification Test (AUDIT) is reviewed. Sensitivities and specificities of the AUDIT for criteria of current hazardous use and, to a slightly lesser extent, lifetime alcohol dependence are high. In general, AUDIT scores are at least moderately related to other self-report alcohol screening tests. Several studies also show them as correlated with biochemical measures of drinking. Results of the AUDIT have also been associated with more distal indicators of problematic drinking. Indices of internal consistency, including Cronbach's α and item-total correlations, are generally in the 0.80's. Future directions for research on the AUDIT are suggested.     

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.     

The Alcohol Dependence Syndrome, 30 years later: a commentary. the 2006 H. David Archibald lecture

AIMS: Major classification systems for alcohol use disorders (DSM-IV and ICD-10) contain elements of the 1976 Edwards and Gross formulation of the Alcohol Dependence Syndrome (ADS). However, issues remain about the criteria that identify Alcohol Dependence (AD) as distinct from Alcohol Abuse (AA) in DSM-IV and Harmful Use in ICD-10. These issues, in part, have their roots in changing historical perceptions of alcohol use and its problems. We discuss current diagnostic criteria for AA and AD, collectively called Alcohol Use Disorders (AUDs), in the context of their historical evolution; research progress in understanding alcohol problems, including alcohol dependence; new findings on the severity of AUDs as classified by DSM-IV; and the role of alcohol consumption patterns in future classifications of AUDs. METHODS: This paper is based largely on the 2006 H. David Archibald Lecture. Parts of the original lecture have been modified to reflect more recent findings from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) of the US National Institute on Alcohol Abuse and Alcoholism (NIAAA). RESULTS: The original Edwards and Gross ADS construct is supported by advances in biological and behavioral science over the past 30 years. New findings indicate that DSM-IV AA and AD are not diagnostically distinct entities, but represent a continuum of severity of AUDs. The ADS criteria may best represent one quantifiable dimension of alcohol use problems and this scale can be related to that of the frequency of harmful patterns of drinking. CONCLUSION: The Edwards and Gross ADS criteria can be used as the basis for beginning the development of scalable multi-dimensional criteria for diagnosing AUDs in new initiatives to revise DSM-IV and ICD-10.     

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.     

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.     

Alcohol use of diabetes patients: the need for assessment and intervention

It is well known that diabetes self-care behaviors are critical to disease progression. Unfortunately, many patients do not adhere to diabetes self-care recommendations despite their importance. Alcohol use has been identified as a barrier to diabetes self-care adherence. Excessive alcohol consumption not only negatively impacts diabetes self-care adherence but also affects the course of diabetes. Diabetes patients who are at-risk drinkers are likely to have poor diabetes treatment adherence, leading to increased morbidity and mortality. Alcohol consumption by diabetes patients is often inadequately assessed and addressed in their medical care. Brief interventions to reduce at-risk drinking have been well validated in a variety of patient populations and offer the potential to improve diabetes treatment adherence and outcome. Assessment and treatment of at-risk drinking could be readily incorporated into routine diabetes care. Strategies for brief assessment of and intervention for at-risk drinking are offered.