Screening Instruments for Alcohol Problems: A Comparison of Cut Points between Mexican American and Mexican Patients in the Emergency Room

The performance of alcohol use disorder screening instruments (CAGE, BMAST, AUDIT, TWEAK) at various cut points were compared between a Mexican American emergency room (ER) sample (n = 586) and a sample of ER patients in Mexico (n = 1,417) using ICD-10 and DSM-IV criteria for alcohol dependence and harmful drinking/abuse by gender and injury status. Lowering cut points improved instrument performance substantially for females in both samples. Further research is needed to explore instrument performance by gender and level of acculturation.     

Selection of screening items for alcohol abuse and alcohol dependence among Mexicans and Mexican Americans in the emergency department.

OBJECTIVE: This article reports on the selection of screening items to detect Mexican or Mexican-American patients in the emergency department (ED) who have alcohol problems and could benefit from an intervention or a referral for treatment. Items are tested against the Rapid Alcohol Problems Screen (RAPS), which has been optimized from standard screening instruments and has outperformed these instruments. METHOD: The performance of individual items from standard screening instruments (CAGE, TWEAK, AUDIT, TRAUMA and BMAST) against International Classification of Diseases, Tenth Revision and Diagnostic and Statistical Manual, Fourth Revision criteria for alcohol abuse and dependence was evaluated in a merged probability sample (N = 869; 72% men) of 537 ED patients from three hospitals in Pachuca, Mexico, and 332 Mexican-American ED patients in Santa Clara County, CA. Logistic regression and tree-classification models were used for item selection. RESULTS: We found a prevalence of 15% for alcohol dependence and a prevalence of 28% for alcohol abuse or dependence in the merged sample. The RAPS items did not perform as well in terms of sensitivity (93%) as the optimal five items identified in these analyses (sensitivity = 98%) for alcohol dependence, but did demonstrate better specificity (79%) than the optimal five items (65%), which is an important consideration in a time of cost containment. Both sets of items showed better sensitivity and positive predictive value but similar Receiver Operating Characteristic values for respondents in the high acculturation group compared to those at other levels of acculturation. Differences in positive predictive value across all subgroups tended to increase at increased cutpoints, especially for the RAPS. CONCLUSIONS: These analyses suggest that the RAPS performs favorably compared to those items optimized, in this sample of Hispanic ED patients. Based on comparative item performance in these analyses, the RAPS may hold promise as a useful tool for screening for alcohol dependence, but requires further evaluation as a stand-alone instrument in comparison with other standard screening instruments.     

Screening for alcohol problems in two emergency service samples in Poland: comparison of the RAPS4, CAGE and AUDIT

Prior research on alcohol-related problems among emergency service patients in Poland found substantial alcohol involvement on the part of injured males, suggesting emergency services may be a productive venue for identifying patients who could benefit from a brief intervention or referral for treatment. Performance of the RAPS4, CAGE and AUDIT against ICD-10 and DSM-IV criteria for alcohol dependence and for alcohol abuse/harmful drinking was compared in probability samples of emergency service patients from two regions of Poland. Sensitivity of the RAPS4 and AUDIT was significantly better than the CAGE for alcohol dependence among males in Warsaw, but specificity was poorer. Among females, although numbers were small, sensitivity for alcohol abuse/harmful drinking and for alcohol dependence or abuse/harmful drinking was significantly better for the RAPS4-QF than for the CAGE or AUDIT at a cut point of 8 across both sites. Performance of the AUDIT at a cut point of 3 was similar to the RAPS4-QF for females. Among males, sensitivity was higher but specificity considerably lower for the RAPS4-QF compared to the CAGE at a cut point of 1 or for the AUDIT at a cut point of 8. Alternate cut points for the AUDIT optimized performance. Findings suggest some regional and gender differences in performance of screening instruments in these Polish samples, but no instrument or cut point is optimal in identifying those with alcohol use disorders. Additional cross-cultural research is needed to evaluate the performance of instruments, especially among females with alcohol use disorders.     

The TWEAK: application in a prenatal setting.

OBJECTIVE: The TWEAK is a screening instrument used to identify women who are risk drinkers. Potential limitations of previous studies of the TWEAK in the prenatal setting include indirect administration of the instrument to minority, indigent pregnant women. The purpose of this study is to assess the efficacy of the TWEAK when it is given directly to a sample of pregnant women of different socioeconomic backgrounds. METHOD: The original TWEAK, with two different tolerance questions, was administered to a sample of 135 pregnant women enrolled in a study of alcohol use during pregnancy at the obstetrics practices of the Brigham and Women's Hospital in Boston, Massachusetts. RESULTS: The TWEAK, using the first tolerance question (number of drinks before feeling the first effects of alcohol) with the cut point set at more than two drinks, had the best predictive ability for lifetime alcohol diagnoses and risk drinking. The sensitivity of the TWEAK can be increased if the cut point for the first tolerance question is set at two drinks, with some loss of specificity and predictive ability. Medical record assessment was the least sensitive but most specific method of identifying alcohol use by pregnant women. CONCLUSIONS: The TWEAK has promise as a screening instrument for identifying risk drinking during pregnancy. Future work should include testing in other clinical populations.     

Drinking Patterns and Problems: A Comparison of Primary Care with the Emergency Room

A comparison is made of drinking patterns and problems of probability samples of noninjured patients drawn from the emergency room (ER) (n = 974) versus primary care clinics (n = 767) in the same metropolitan community. Those in the primary care sample were significantly less likely to report heavier drinking, consequences of drinking, alcohol dependence, and ever having treatment for an alcohol problem, controlling for demographic differences between the two sites. The data suggest that while primary care settings remain an important site for early identification and intervention for problem drinking, the ER may hold more potential for targeting prevention efforts in an era of reduced resources.     

Alcohol use and misuse in urban Mexican men and women: an epidemiologic perspective

Consumption patterns and misuse of alcohol were examined in adults sampled from three cities in Mexico (n=1933). The sample was divided into groups of persons who abstained from alcohol, drank but endorsed no misuse, or drank and endorsed at least some misuse of alcohol. Half of the entire sample was categorized as drinkers (12 or more drinks in lifetime). Mexican men drank more per occasion and reported more problems with alcohol rather than did Mexican women. Low socioeconomic resources, not being married, and female gender were related to whether Mexicans abstained from alcohol rather than drank without misuse. Lifetime posttraumatic stress disorder (PTSD) or depression increased the likelihood of misusing alcohol versus drinking without misuse, as did greater amount of drinks consumed per occasion and male gender. Younger age and not being married were also related to misuse, although this was true mostly for women. The number of traumatic experiences in childhood and lower socioeconomic resources also predicted misuse, although mostly for men. Specific traumatic experiences and their relationship to alcohol use and misuse were also examined.     

Alcohol expectancies and drinking behaviors in Mexican American college students

Research with non-Latinos has shown that alcohol expectancies ("the anticipated effects of alcohol use") are associated with drinking behaviors; however, prior studies have not fully examined such relations in Latino college students. This investigation examines positive alcohol expectancies and their association with contextual drinking and alcohol-related problem behaviors in a sample of 107 Mexican American college students (mean age=25; 54% female) who completed self-report surveys. Results showed that students who endorsed expectancies of physical and social pleasure and increased social assertiveness were likely to engage in frequent heavy drinking and imbibe in less personal settings. Furthermore, gender (being male) and the expectancy of enhanced sexual performance and experience were associated with involvement in risk behaviors due to drinking. This study highlights the link between specific alcohol expectancies and alcohol-related problem behaviors in Mexican American college students. Intervention approaches aimed at modifying drinking expectancies in physical, social, and sexual domains could prove useful in this population.     

Persistent cognitive deficits in community-treated alcoholic men and women volunteering for research: limited contribution from psychiatric comorbidity

OBJECTIVE: The contribution of psychiatric comorbidity to cognitive status was assessed in a sample of treatment-seeking alcoholics who met criteria to participate in studies of effects of chronic alcohol misuse on brain structure and cognition. METHOD: Alcoholic men (n = 43) and women (n = 21) who responded to notices about a research study were screened, clinically assessed and administered Wechsler Memory and Intelligence tests after 3 months of sobriety, on average. Cognitive performance was compared with that of an age-matched sample of healthy controls (n = 51). RESULTS: As a group, the alcoholics achieved significantly lower scores than controls on summary indices of the Wechsler Memory and Adult Intelligence Scales and showed greater decline from estimated premorbid intelligence levels than controls. Almost 60% of the alcoholics had at least one additional psychiatric (mood or anxiety) or past substance-dependence comorbidity. There were no marked sex differences in patterns of comorbidity. Comorbid alcoholics were younger, had consumed less alcohol over their lifetime and performed between noncomorbid alcoholics and controls on all tests. CONCLUSIONS: Mood and anxiety comorbidity did not necessarily compound poor cognitive test performance associated with chronic alcohol misuse. While unexpected, this finding suggests that, in this sample, poorer cognitive performance was more a function of alcoholism per se than nonalcoholic comorbidity.     

Violence related injuries in the emergency room: alcohol, depression, and conduct problems

OBJECTIVE: The aim of this study was to obtain epidemiological measures of the association between alcohol consumption and emergency room (ER) attendance due to violence, compared to the general population in the city of Pachuca, Mexico, during October-November, 1996 and June-July, 1997. METHOD: The study was a population-based case-control design. Intervention and Measurements: Data consisted of an interviewer-administered questionnaire, collected on a 24-h basis, during the entire week. Setting and Participants: Cases were 127 patients (78% male) admitted to the ER because of an injury that was the result of violence (being in a fight or being attacked by someone). A sample of residents from Pachuca (n = 920) was the comparison group. RESULTS: Patients reporting drinking within 6h compared to nondrinkers were more likely to suffer a violence-related injury [34.0 (17.5-66.2)] and alcohol dependent patients were more likely to be involved in a violence-related injury [7.4 (3.5-15.6)] compared to noncurrent drinkers. When both alcohol prior and alcohol dependence were considered simultaneously in multiple models among current drinkers, patients with violence-related injuries were more likely to report alcohol prior but not to be positive for alcohol dependence. Depressive symptoms, but not conduct problem behavior, were also associated with violent injury in simultaneous regressions that included alcohol variables. CONCLUSIONS: In the city of Pachuca, Mexico, a large relationship between drinking prior to the event and violence-related injury, regardless of alcohol dependence, was found. Depression was also related to violence, suggesting the need for more comprehensive intervention with these patients.     

The reliability and validity of the Alcohol Use Disorders Identification Test (AUDIT) in a German general practice population sample

OBJECTIVE: Our goal was to analyze the retest reliability and validity of the Alcohol Use Disorders Identification Test (AUDIT) in a primary-care setting and recommend a cut-off value for the different alcohol-related diagnoses. METHOD: Participants recruited from general practices (GPs) in two northern German cities received the AUDIT, which was embedded in a health-risk questionnaire. In total, 10,803 screenings were conducted. The retest reliability was tested on a subsample of 99 patients, with an intertest interval of 30 days. Sensitivity and specificity at a number of different cut-off values were estimated for the sample of alcohol consumers (n=8237). For this study, 1109 screen-positive patients received a diagnostic interview. Individuals who scored less than five points in the AUDIT and also tested negative in a second alcohol-related screen were defined as "negative" (n=6003). This definition was supported by diagnostic interviews of 99 screen-negative patients from which no false negatives could be detected. As the gold standard for detection of an alcohol-use disorder (AUD), we used the Munich-Composite International Diagnostic Interview (MCIDI), which is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. RESULTS: On the item level, the reliability, measured by the intraclass correlation coefficient (ICC), ranged between .39 (Item 9) and .98 (Item 10). For the total score, the ICC was .95. For cut-off values of eight points and five points, 87.5% and 88.9%, respectively, of the AUDIT-positives, and 98.9% and 95.1%, respectively, of the AUDIT-negatives were identically identified at retest, with kappa = .86 and kappa = .81. At the cut-off value of five points, we determined good combinations of sensitivity and specificity for the following diagnoses: alcohol dependence (sensitivity and specificity of .97 and .88, respectively), AUD (.97 and .92), and AUD and/or at-risk consumption (.97 and .91). CONCLUSIONS: Embedded in a health-risk questionnaire in primary-care settings, the AUDIT is a reliable and valid screening instrument to identify at-risk drinkers and patients with an AUD. Our findings strongly suggest a lowering of the recommended cut-off value of eight points.     

Psychometric properties of a quitting time for alcohol questionnaire: factor structure, reliability, and validity.

Research into the dynamics of alcohol use has traditionally focused on etiological factors, particularly on the reasons an individual engages in drinking behaviours. Although reasons for the permanent cessation of drinking have also been well documented, little is known about the reasons for the episodic cessation of alcohol use that is characteristic of nonproblematic drinking patterns. The purpose of the present study was to develop and validate a questionnaire designed to monitor the reasons an individual temporarily stops drinking at the end of a drinking episode. A 23-item Quitting Time for Alcohol Questionnaire (QTAQ) was developed and distributed to a community based sample of 252 participants. Factor analysis revealed three conceptually distinct factors, QTAQ-IS (Internal Status) QTAQ-AA (Avoidance Adherence) and QTAQ-IC (Immediate Context), which accounted for 36.3% of the variance. Cross-validation on a large sample of undergraduate students (N = 479) confirmed the three-factor solution (accounting for 33% of the variance). Cronbach's alpha coefficients for the factors ranged from .74 to .81 for the community sample and from .62 to .78 for the student sample. The validity of the emergent factors was demonstrated by their ability to classify participants according to self-reported alcohol consumption and alcohol dependence criteria, and also by their significant predictive relationship with these criteria. The present findings suggest that the QTAQ is a useful instrument both for research and for use in clinical practice.     

Attentional bias and alcohol dependence: a controlled study using the modified stroop paradigm

Detoxified clients at an alcohol treatment centre (n = 34) were administered a modified Stroop test, an index of attentional bias or distraction. Their performance was compared to controls (n = 33) who were staff recruited from specialist substance misuse clinics based on the presumption of familiarity with the alcohol and addiction related terms of the Stroop task. The card-format Stroop test contained words such as "alcohol" and "relapse" and neutral, semantically homogenous words such as "table" and "chair." Analysis of variance (ANOVA) revealed significant main effects for word type with both the clinic attendees and controls taking longer to colour-name alcohol-related words. Predicted interactions between word type and subject status were not observed. These findings suggest that both problem drinkers and clinic staff did not differ significantly in the degree of Stroop interference displayed, although a trend towards greater distraction by clinic attendees with alcohol-related terms was noted. The statistically significant results were nonetheless consistent with findings that expertise or familiarity can be influential factors in Stroop performance. Multiple regression analyses with the entire sample (n = 65) showed that psychometric and self-reported indices of alcohol dependence and consumption were predictive of Stroop interference. This is consistent with the existence of a acquired information processing bias related to escalating alcohol use and dependence such as that proposed by Tiffany [Psychol. Rev. 97 (1990) 147.].     

Screening for drug use disorders in the emergency department: performance of the rapid drug problems screen (RDPS)

Little research is available on brief screening instruments for identify those meeting diagnostic criteria for drug dependence or abuse. A brief, four-item screening instrument, called the rapid drug problems screen (RDPS), was developed from a similar instrument for alcohol use disorders, the rapid alcohol problems screen (RAPS). Performance of the RDPS was evaluated against DSM-IV and ICD-10 criteria for drug dependence and for dependence or abuse in a sample of 703 emergency department patients in Mexico City. Among males, sensitivity and specificity were 91 and 96%, respectively, for dependence and 93 and 96%, respectively, for dependence or abuse. Neither of the two females meeting diagnostic criteria for dependence or abuse were identified by the RDPS. Area under the receiver-operating characteristic curve indicates an optimum cut point of 1. The data suggest that the RDPS may hold promise as a brief screening instrument for substance use among males, but should be tested in larger populations of females meeting diagnostic criteria for drug use disorders, and across ethnic subgroups in other geographic locales.     

Validation of the Alcohol Use Disorders Identification Test (AUDIT) in urban community outreach and de-addiction center samples in north India

OBJECTIVE: The Alcohol Use Disorders Identification Test (AUDIT) developed by the World Health Organization for screening disorders related to alcohol use has been shown to have robust psychometric properties. This study compared the performance of AUDIT with that of the Short Michigan Alcoholism Screening Test (SMAST) in a region of North India. METHOD: A total of 297 consecutive subjects who had used alcohol in the past year were recruited from a de-addiction center (DAC) (n = 97) and a community outreach setting (n = 200) in West Delhi. Using International Classification of Diseases, Tenth Edition (ICD-10) criteria, the relative effectiveness of the AUDIT and the SMAST in identifying alcohol-use-related disorders was assessed and compared. Internal consistency and interscale correlations were evaluated, along with sensitivity, specificity and ROC curve analyses. RESULTS: The AUDIT had very high internal reliability (alpha 0.92) in this Indian sample. There was, in general, good correlation between the total and factor scores of the AUDIT and SMAST (ranging from 0.28 to 0.97), which were higher in the community than in the DAC sample. The AUDIT (area under the curve [AUC] = 0.883) and SMAST (AUC = 0.870) were similar in detecting harmful use of alcohol. The AUDIT optimal cutoff score was 16 (sensitivity 85.3, specificity 89.4) for ICD-10 harmful use and 24 (sensitivity 69.4, specificity 87.5) for ICD-10 alcohol dependence. CONCLUSIONS: The AUDIT and SMAST seem to be comparable in their ability to screen subjects with alcohol use disorders. The AUDIT score for screening harmful use in the sample appears to be higher than previously reported. The utility of such high cutoff for screening subjects for intervention is obvious, but it is quite likely that some positive cases might be missed.     

Test of association between TaqIA A1 allele and alcohol use disorder phenotypes in a sample of adolescent patients with serious substance and behavioral problems

Several studies have demonstrated a significant association between the A1 allele of the TaqIA polymorphism and various phenotypes of alcoholism, others have not, and two studies have shown the reversed association, where the A2 allele was associated with higher levels of alcohol consumption. We sought to test for an association between early onset (in childhood or adolescence) alcohol use disorders and the DRD2 TaqIA polymorphism and to resolve some of the hypothesized explanations for previous negative results, utilizing a larger sample than many previous studies. METHODS: We selected individuals with a lifetime alcohol abuse or dependence (n=239) diagnosis from a clinically ascertained sample of youth (ages 13-19) with serious conduct and substance problems (about 90% also met criteria for conduct disorder and a cannabis use disorder) and compared them with individuals without a lifetime alcohol use disorder diagnosis ascertained from (1) community adolescent controls (n=151), (2) siblings of patients (n=87) and (3) other adolescent patients (n=92). Cases were compared with each control group, separately, by genotype using the chi(2)-test. Using 78 adolescent patients with an alcohol use disorder where genotypic information was available for both parents, we conducted the transmission disequilibrium test (TDT). RESULTS: Case-control results were non-significant using the entire community control sample (chi(2)(2)=1.92; p=0.38) and when restricting the sample to Caucasians (chi(2)(2)=3.81; p=0.15) or Hispanics (chi(2)(2)=1.70; p=0.43). Case-control results using the other comparison groups and TDT results were also non-significant. DISCUSSION: We did not find support for an association between the TaqIA polymorphism and early onset alcohol use disorders.     

Screening for cannabis use disorders in an adolescent emergency department sample

Cannabis, more often than alcohol, is the drug mentioned in substance-related reasons for treatment of an adolescent in an emergency department (ED). This study examined the prevalence of DSM-IV cannabis and alcohol diagnoses in an adolescent ED sample, evaluated the performance (i.e. sensitivity and specificity) of DSM-IV cannabis symptoms and other screening items as indicators of cannabis diagnosis status, and examined parent-adolescent agreement on the presence of cannabis and alcohol diagnoses. Adolescents (ages 13-19, n=442) admitted to an ED for a non-substance-related injury were administered the diagnostic interview schedule for children (DISC). Parents (n=272) of adolescents younger than age 18 completed the DISC-parent version to report on their child's drug use. A minority met criteria for a current DSM-IV cannabis or alcohol diagnosis: 7.9% for both alcohol and cannabis, 7.5% for cannabis-only, and 9.0% for alcohol-only. Frequency of cannabis use had the best overall performance in discriminating those with and without a cannabis diagnosis compared with items on perceived risk of cannabis use, peer cannabis use, and alcohol and cigarette use. Parent reports generally underestimated the adolescent's substance use. Questions on level of substance use generally provide an efficient method of screening adolescents for substance-related problems in an ED setting.     

Alcohol Consumption Patterns: Gay and Lesbian Urban Ethnic Minority Members

ABSTRACT

The aim of this study was to assess patterns of alcohol consumption and alcohol related problems in a sample of lesbian and gay NYC residents. There were no differences between lesbian (n = 93) and gay (n = 90) subgroups with regard to alcohol use and health related variables. The average number of drinking days reported for the previous 30 day period was 6.87 (SD 7.0) and 16% of the sample reported consuming more than 4 drinks per drinking day. Age, educational level, and feelings of excessive restlessness were associated with alcohol use. Although there have been reports of increased rates of alcohol use and alcohol related problems in the lesbian and gay population, this is not reflected in this sample.     

Effects of alcohol on psychomotor performance and perceived impairment in heavy binge social drinkers

Alcohol intoxication often results in negative consequences; however, specific behavioral and subjective effects vary as a function of individual differences. The present study utilized an alcohol challenge paradigm to examine whether heavy binge social drinkers (HD; n=77), compared to light social drinkers (LD; n=55), exhibit: (1) greater tolerance in psychomotor task performance under the influence of alcohol, and (2) differential perceptions of the impairing effects of alcohol. The study included three test sessions in which participants consumed either a low (0.4 g/kg) or a high (0.8 g/kg) dose of ethanol or a placebo beverage administered in random order and counterbalanced within group. Participants completed the Digit-Symbol Substitution Task (DSST) and the Grooved Pegboard at pre-drink baseline and at multiple time points after beverage consumption. They also completed a scale of perceived impairment at several intervals after beverage consumption. Ethanol impaired performance at the high dose, but not at the low dose (ps<.001). The groups exhibited similar alcohol-induced impairment. However, HD reported lower self-perceived impairment compared to LD, particularly during the early portion of the blood alcohol curve when actual impairment was most pronounced (p<.001). Thus, this study extends prior research in that habitual binge social drinking does not appear to be associated with tolerance to alcohol's impairing effects on select psychomotor skills. Further, results may have implications for alcohol-related harm as binge social drinkers regularly consume intoxicating doses of alcohol but may not be aware of the physical and cognitive impairments produced by alcohol.     

Acculturation status and heavy alcohol use among Mexican American college students: investigating the moderating role of gender

We examined whether gender moderates the association between acculturation and heavy alcohol use. The sample consisted of 126 Mexican American college students (Mean age=24.7 years; 57% female) who completed self-report measures of heavy alcohol use, acculturation status (global acculturation and ethnic identity), and relevant control variables (age, peer alcohol use). Multivariable regression revealed that higher levels of ethnic identity were associated with greater frequency of heavy alcohol among men. Conversely, neither measure of acculturation was associated with heavy alcohol use among women. These findings suggest that interventions for Latino/a students should consider the role of culturally relevant variables in heavy alcohol use, particularly for men. They also have implications regarding how acculturation is operationalized in alcohol studies, and suggest directions for future research.     

An examination of the utility of the AUDIT in people with schizophrenia

OBJECTIVE: To examine the reliability and validity of the Alcohol Use Disorders Identification Test (AUDIT) compared to a structured diagnostic interview, the Composite International Diagnostic Interview (CIDI; 12-month version) in psychiatric patients with a diagnosis of schizophrenia. METHOD: Patients (N = 71, 53 men) were interviewed using the CIDI (Alcohol Misuse Section; 12-month version) and then completed the AUDIT. RESULTS: The CIDI identified 32.4% of the sample as having an alcohol use disorder. Of these, 5 (7.0%) met diagnostic criteria for harmful use of alcohol, 1 (1.4%) met diagnostic criteria for alcohol abuse and 17 (23.9%) met diagnostic criteria for alcohol dependence. The AUDIT was found to have good internal reliability (coefficient = 0.85). An AUDIT cutoff of > or = 8 had a sensitivity of 87% and specificity of 90% in detecting CIDI-diagnosed alcohol disorders. All items except Item 9 contributed significantly to discriminant validity. CONCLUSIONS: The findings replicate and extend previous findings of high rates of alcohol use disorders in people with severe mental illness. The AUDIT was found to be reliable and valid in this sample and can be used with confidence as a screening instrument for alcohol use disorders in people with schizophrenia.