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

Screening student drinking behaviors: examining AUDIT criterion validity using CIDI-based alcohol use disorder as the 'gold standard'

Introduction

High levels of alcohol consumption among college students have been observed across countries. Heavy drinking episodes are particularly prevalent in this population, making early identification of potentially harmful drinking critical from a public health perspective. Short screening instruments such as the Alcohol Use Disorders Identification Test (AUDIT) are serviceable in this regard. However, there is a need for studies investigating the criterion validity of AUDIT in the student population. The aim was to examine the criterion validity of the full AUDIT and AUDIT-C (the first three items directly gauging consumption patterns) in a sample of college and university students using 12-month prevalence of alcohol use disorder derived from an electronic, self-administered version of the World Health Organization (WHO) Composite International Diagnostic Interview, fifth version (CIDI 5.0), which serves as the 'gold standard'.

Methods

The study population of the current study is derived from the SHoT study (Students' Health and Wellbeing Study), which is a large national survey of students enrolled in higher education in Norway. In a follow-up study of mental disorders among participants of the SHoT2022 study, students were invited to complete a self-administered electronic version of the CIDI. A random sample of 4,642 participants in the nested CIDI-sample was asked to fill out a set of screening instruments, including AUDIT, before starting CIDI. Based on Youden Index maximization, we estimated the sex-specific optimal cut-offs for AUDIT and AUDIT-C in relation to alcohol use disorder, as determined by CIDI.

Results

For the full AUDIT, the optimal cut-offs were 9 for males and 10 for females. The corresponding cut-offs for AUDIT-C were 6 for males and 5 for females. The same optimal cut-offs for both the full AUDIT and AUDIT-C were replicated in bootstrapped analyses with 1,000 runs.

Conclusion

The full AUDIT demonstrated acceptable criterion validity with a balance between sensitivity and specificity. However, for AUDIT-C, caution should be exercised when interpreting screening results among college and university students. In conclusion, the full AUDIT is a reliable screening instrument for college and university students, while further modification may be needed for AUDIT-C in this setting.

Screening for harmful substance use in emergency departments: a systematic review

BACKGROUND

Substance use-related emergency department (ED) visits have increased substantially in North America. Screening for substance use in EDs is recommended; best approaches are unclear. This systematic review synthesizes evidence on diagnostic accuracy of ED screening tools to detect harmful substance use.

METHODS

We included derivation or validation studies, with or without comparator, that included adult (≥ 18 years) ED patients and evaluated screening tools to identify general or specific substance use disorders or harmful use. Our search strategy combined concepts Emergency Department AND Screening AND Substance Use. Trained reviewers assessed title/abstracts and full-text articles for inclusion, extracted data, and assessed risk of bias (QUADAS-2) independently and in duplicate. Reviewers resolved disagreements by discussion. Primary investigators adjudicated if necessary. Heterogeneity precluded meta-analysis. We descriptively summarized results.

RESULTS

Our search strategy yielded 2696 studies; we included 33. Twenty-one (64%) evaluated a North American population. Fourteen (42%) applied screening among general ED patients. Screening tools were administered by research staff (n = 21), self-administered by patients (n = 10), or non-research healthcare providers (n = 1). Most studies evaluated alcohol use screens (n = 26), most commonly the Alcohol Use Disorders Identification Test (AUDIT; n = 14), Cut down/Annoyed/Guilty/Eye-opener (CAGE; n = 13), and Rapid Alcohol Problems Screen (RAPS/RAPS4/RAPS4-QF; n = 12). Four studies assessing six tools and screening thresholds for alcohol abuse/dependence in North American patients (AUDIT ≥ 8; CAGE ≥ 2; Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV-2] ≥ 1; RAPS ≥ 1; National Institute on Alcohol Abuse and Alcoholism [NIAAA]; Tolerance/Worry/Eye-opener/Amnesia/K-Cut down [TWEAK] ≥ 3) reported both sensitivities and specificities ≥ 83%. Two studies evaluating a single alcohol screening question (SASQ) (When was the last time you had more than X drinks in 1 day?, X = 4 for women; X = 5 for men) reported sensitivities 82-85% and specificities 70-77%. Five evaluated screening tools for general substance abuse/dependence (Relax/Alone/Friends/Family/Trouble [RAFFT] ≥ 3, Drug Abuse Screening Test [DAST] ≥ 4, single drug screening question, Alcohol, Smoking and Substance Involvement Screening Test [ASSIST] ≥ 42/18), reporting sensitivities 64%-90% and specificities 61%-100%. Studies' risk of bias were mostly high or uncertain.

CONCLUSIONS

Six screening tools demonstrated both sensitivities and specificities ≥ 83% for detecting alcohol abuse/dependence in EDs. Tools with the highest sensitivities (AUDIT ≥ 8; RAPS ≥ 1) and that prioritize simplicity and efficiency (SASQ) should be prioritized.

Could reasons for admission help to screen unhealthy alcohol use in emergency departments? A multicenter French study

Background

Many patients admitted to general emergency departments (EDs) have a pattern of drinking that could lead to future alcohol-related complications. However, it is often difficult to screen these patients in the context of emergency. The aim of this study is to analyze whether reasons for admission could help to screen patients who have an unhealthy alcohol use.

Method

Patients were recruited among six public hospital ED in France, between 2012 and 2014. During a one-month period in each hospital, anonymous questionnaires including sociodemographic questions, AUDIT-C and RAPS4-QF were administered to each patients visiting the ED. The reason for admission of each patient was noted at the end of their questionnaire by the ED practitioner.

Results

Ten thousand Four hundred twenty-one patients were included in the analysis. Patients who came to the ED for injuries and mental disorders were more likely to report unhealthy alcohol use than non-harmful use or no use. Among male patients under 65 years old admitted to the ED for a mental disorder, 24.2% drank more than four drinks (40 g ethanol) in typical day at least four time a week in the last 12 months. Among these patients, 79.7% reported daily or almost daily heavy episodic drinking (HED, 60 g ethanol), and all were positive on the RAPS4-QF.

Conclusion

This study highlights that unhealthy alcohol use is frequent among ED patients and particularly among those who come for injuries or mental disorders. Men under 65 years old with a mental disorder require special attention because of their increased prevalence of daily or almost daily HED.

Does the Fast Alcohol Screening Test Accurately Distinguish Between Harmful and Severely Dependent Tiers of Alcohol Misuse?

AIMS

Primary aim: to determine the efficacy of FAST (the Fast Alcohol Screening Test) for detecting harmful and dependent levels of alcohol use. Secondary aim: to compare the performance of the FAST to two short forms of the Alcohol Use Disorder Identification Test (AUDIT): the AUDIT-C and AUDIT-3.

METHODS

Data from 3336 individuals in South Wales, compiled from full AUDIT datasets, were examined. AUROC analysis, alongside measures of sensitivity and specificity of the FAST, AUDIT-C and AUDIT-3 were utilized for the identification of harmful and dependent alcohol use.

RESULTS

The FAST demonstrated efficacy in the identification of harmful and dependent levels of alcohol use, with superior performance to both the AUDIT-C and AUDIT-3.

CONCLUSION

The present paper demonstrates the potential of the FAST as a cost- and time-effective method for appropriate screening and signposting in the stepped care model utilized by many health care and treatment services. Further studies are needed to ensure validity, both within the general population and for specific services and populations.

The Association between Reward Sensitivity and Activity Engagement: the Influence of Delay Discounting and Anhedonia

Aim

Reward sensitivity affects individuals’ motivation to engage in goal-directed behavior. Other concepts, critical for reward appraisal, that potentially influence activity participation encompass delay discounting and anhedonia. The aim of this study was to test the hypothesis that anhedonia and delay discounting influence the relationship between reward sensitivity and activity engagement.

Methods

In total, 37 inpatient patients with an alcohol use disorder (AUD) and 37 matched healthy controls completed the behavioral activation system scale (BAS scale), the Pleasant Activities List (PAL), the Snaith–Hamilton Pleasure Scale (SHAPS) and the Delay Discounting Task (DDT).

Results

Patients differed from controls on SHAPS, DDT-k, PAL substance-related activities (SRA), but not BAS and PAL non-substance-related activities (non-SRA). Correlational analyses revealed a strong correlation between BAS and PAL non-SRA in both patients (r = 0.53) and controls (r = 0.47), but also with PAL-SRA in patients (r = 0.40), although not controls (r = 0.09). BAS was negatively correlated with SHAPS in both groups and with DDT in controls. SHAPS was negatively linked to PAL non-SRA in both groups. The BAS-PAL non-SRA relationship was influenced by discount rates in controls.

Conclusion

A strong link exists between reward sensitivity and engagement in non-SRA in both groups. Delay discounting affects the reward sensitivity and non-SRA association in healthy controls, while anhedonia did not impact the association between reward sensitivity and engagement in (non-)SRA in both conditions.

Characteristics and Predictors of Heavy Episodic Drinking (HED) among Young People Aged 16-25: The International Alcohol Control Study (IAC), Tshwane, South Africa

In South Africa, little is known about alcohol consumption patterns, such as drinks consumed, container size, salience of alcohol price, affordability and availability, and perceptions of alcohol policies as potential predictors of heavy episodic alcohol (HED) use among young people. This paper examines predictors of HED among young people with specific consideration given to these alcohol consumption patterns. This study conducted in the Tshwane Metropole in 2014 employed multi-stage stratified cluster random sampling. Participants were between the ages 16–25 years. A structured questionnaire was used to collect data. Of the 287 (n = 678) participants who had used alcohol in the past six months and for whom we had complete consumption data, almost half were identified as heavy episodic drinkers (HEDs) and were significantly more likely to consume alcohol on a daily basis (p = 0.001). Having nightclub as the primary drinking location (p = 0.023) and drinking from a container size bigger than one standard drink (p = 0.014) were significant predictors for HED. HEDs were also more likely to have a perception that most people consume alcohol (p = 0.047). The results point to HED of alcohol among young people who drink in South Africa, highlighting the need for multicomponent interventions.

Auditing the AUDIT: A systematic review of cut-off scores for the Alcohol Use Disorders Identification Test (AUDIT) in low- and middle-income countries

INTRODUCTION

The World Health Organization's (WHO) Alcohol Use Disorders Identification Test (AUDIT) is used extensively across the world, with cut-off scores recommended by the WHO. We reviewed the use and validity of AUDIT cut-off scores in low- and middle-income countries as cultural contexts are expected to influence the detection of alcohol use disorders.

MATERIALS AND METHODS

The systematic review was guided by an a priori defined protocol consistent with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. We searched Cochrane library, Medline, EMBASE, PsycINFO, CINAHL, Indmed, LILACS, and AJOL databases using appropriate search terms. We conducted a narrative synthesis of the data.

RESULTS

We identified 54 distinct studies that used AUDIT cut-off scores which were not in alignment with those recommended by the WHO. India (n = 10), Nigeria (n = 9), and Brazil (n = 9) produced most of these included studies. Most of the studies (n = 42) did not conduct psychometric evaluations of AUDIT cut-off scores. Of the twelve studies which did report psychometric results, a wide range of cut-off scores performed well. In these studies the cut-off scores to detect hazardous drinking ranged from >3 to >5, for harmful drinking from >5 to >16, and for dependent drinking from >7 to >24.

DISCUSSION

AUDIT is being widely used in LMICs and non-recommended cut-off scores are considered to be appropriate in these countries. It is important to systematically evaluate the psychometric properties of those cut-off scores to ensure the internal validity of the studies in which they are used.

Single episode of alcohol use resulting in injury: a cross-sectional study in 21 countries

OBJECTIVE

To examine the empirical basis for including the diagnostic category of "a single episode of harmful substance use" in the 11th revision of the International statistical classification of diseases and related health problems (ICD-11).

METHODS

We used data on patients admitted to emergency departments in 21 countries with alcohol-related injuries (i.e. with drinking within the preceding six hours) who had no sign of alcohol intoxication or withdrawal, no alcohol in blood and no sign of alcohol dependence or harmful drinking as described in the ICD-10. We obtained data on alcohol-related injuries, the patient's causal attribution of injury to drinking, the alcohol amount consumed, blood alcohol concentration and usual drinking pattern. Patients with and without alcohol dependence or harmful drinking were compared.

FINDINGS

We included a representative sample of 18 369 patients. After adjustment for unequal sampling, 18.8% reported drinking in the six hours before injury and 47.1% of these attributed their injury to drinking; 16.3% of those reporting drinking and 10.3% of those attributing their injury to drinking were not alcohol dependent or harmful drinkers. The majority of these last two groups reported never having had five or more drinks on one occasion during the last year and had a blood alcohol concentration less than 0.05%.

CONCLUSION

Some individuals attending emergency departments had alcohol-attributable injuries due to a single episode of drinking but had no history of harmful use or dependence. These findings highlight the public health relevance of including the new diagnostic category in the ICD-11.

Validity of the CAGE questionnaire for men who have sex with men (MSM) in China

BACKGROUND

Detection of heavy drinking among men who have sex with men (MSM) is crucial for both intervention and treatment. The CAGE questionnaire is a popular screening instrument for alcohol use problems. However, the validity of CAGE for Chinese MSM is unknown.

METHOD

Data were from three waves of cross-sectional assessments among general MSM (n=523) and men who sell sex to other men ("money boys" or MBs, n=486) in Shanghai, China. Specifically, participants were recruited using respondent-driven, community popular opinion leader, and venue-based sampling methods. The validity of the CAGE was examined for different cutoff scores and individual CAGE items using self-reported heavy drinking (≥14 drinks in the past week) as a criterion.

RESULTS

In the full sample, 75 (7.4%) of participants were classified as heavy drinkers. 32 (6.1%) of general MSM and 43 (8.9%) of MBs were heavy drinkers. The area under curve statistics for overall sample was 0.7 (95% CI: 0.36-0.77). Overall, the sensitivities (ranging from 18.7 to 66.7%), specificities (ranging from 67.5 to 95.8%), and positive predictive values (ranging from 14.1 to 26.4%) for different cutoff scores were inadequate using past week heavy drinking as the criterion. The ability of CAGE to discriminate heavy drinkers from non-heavy drinkers was limited.

CONCLUSIONS

Our findings showed the inadequate validity of CAGE as a screening instrument for current heavy drinking in Chinese MSM. Further research using a combination of validity criteria is needed to determine the applicability of CAGE for this population.

Does Brief Intervention Work For Heavy Episodic Drinking? A Comparison of Emergency Department Patients in Two Cultures

Little has been reported on the efficacy of brief intervention (BI) among heavy episodic drinkers, although this drinking style is known to be especially harmful in relation to negative consequences including alcohol-related injuries. The comparative efficacy of BI is analyzed in two similar randomized controlled clinical trials of emergency department (ED) patients in two different cultures, both of which exhibit similar drinking styles of heavy episodic drinking: Poland and Mexican-Americans in the U.S. Improvements in drinking and problem outcomes are analyzed at 3-month and 12-month follow-up, using random effects modeling, among 446 Polish patients and 698 Mexican-American patients, randomized to screened only, assessment, and intervention conditions in each study. In Poland significant improvement was observed in all outcome measures for the assessed condition at 3-months compared to baseline, but only in the two problem variables at 12-months, while for the intervention condition, significant improvement was found in all outcome measures at both time periods; however, estimates of the interaction terms were not statistically significant. In the Mexica-American study, while significant improvement in nearly all outcome measures were observed at 3 months and 12 months for both conditions, estimates of the interaction terms suggest that for all drinking variables, but not problem variables, outcomes were significantly improved for the intervention condition over the assessed condition at 12 months, suggesting a 12-month intervention effect. Findings here are non-conclusive regarding a treatment effect of BI for heavy episodic drinking in ED patients. Given the mixed findings for BI in other ED studies, future studies need to explore the efficacy of BI in other populations and cultures exhibiting different drinking patterns to help identify what type of drinker would most benefit from BI in the ED setting.

Performance of the RAPS4/RAPS4-QF for DSM-5 compared to DSM-IV alcohol use disorders in the general population: Data from the 2000-2010 National Alcohol Surveys

BACKGROUND

A number of relatively short screening instruments have been developed for identifying alcohol use disorders (AUD), but performance has been evaluated against the standard Diagnostic and Statistical Manual of Mental and Behavior Disorders (DSM) criteria, and it is not known how screening instruments may perform based on the newly formulated DSM-5 criteria, which is a radical departure from previous versions of the DSM. Analyzed here is the performance of the RAPS4/RAPS4-QF against DSM-5 criteria for AUD compared to DSM-IV dependence and abuse criteria.

METHODS

Sensitivity and specificity are analyzed in a merged sample of 21,386 respondents from three National Alcohol Surveys of the U.S. general population (2000, 2005, 2010).

RESULTS

Sensitivity of the RAPS4 was lower for DSM-5 AUD (62.5%) than for DSM-IV dependence (88%), while the RAPS4-QF was higher for DSM-5 AUD (90.3%) than for DSM-IV abuse (81.3%), or abuse/dependence (85.8%), while maintaining good specificity (84%). Sensitivity of the RAPS4-QF was higher for males (92%) compared to females (86.6%) and highest for whites (93.8%) followed by Hispanics (84.2%) and blacks (82.4%).

CONCLUSIONS

Screening instruments may not perform similarly for DSM-5 as for DSM-IV AUD, and data here suggest the RAPS4-QF may be a good instrument choice for identifying those meeting criteria for DSM-5 AUD. These data also suggest the need for additional research and a similar evaluation of other commonly used screening instruments for DSM-5 AUD.

Comparison of different methods assessing alcohol contribution to emergency room visits

INTRODUCTION

The main objective of research was to compare different methods of assessing alcohol's contribution to injuries and medical conditions treated in ER in Poland. Four methods are discussed, including breathalyzer reading, clinical appraisal following Y91 codes of ICD 10, interviewer's observation and self-report.

METHODS

In two Polish sites Warsaw and Sosnowiec probability samples of patients admitted to ER were selected and interviewed face-to-face by trained interviewers. Almost 1.5 thousand patients were interviewed with response rate of 67%. To identify injuries and medical conditions associated with drinking (preceded by alcohol consumption) four methods were used: clinical observations made by nurses trained in applying Y91 codes of ICD-10 (in the Sosnowiec ER only), observations by interviewers who did not receive such a training, breathalyzer readings and patient self-reports of drinking within six hours prior to the event.

RESULTS

A breathalyzer reading identified 4.5% under the influence of alcohol among all patients, and 5.7% among those who were breathalyzed. Clinical assessment in Sosnowiec and interviewers' observations in both cites identified almost the same proportion: 5.1% and 4.7%, respectively and self-reports almost 10%. All four measures for identifying potentially alcohol related ER visits found a total of 11.5% cases among sampled patients.

How CAGE, RAPS4-QF, and AUDIT Can Help Practitioners for Patients Admitted with Acute Alcohol Intoxication in Emergency Departments?

AIMS

To help clinicians to identify the severity of alcohol use disorders (AUDs) from optimal thresholds found for recommended scales. Especially, taking account of the high prevalence of alcohol dependence among patients admitted to the emergency department (ED) for acute alcohol intoxication (AAI), we propose to define thresholds of severity of dependence based on the AUDIT score.

METHODS

All patients admitted to the ED with AAI (blood alcohol level >0.8 g/L), in a 2-month period, were assessed using the CAGE, RAPS-QF, and AUDIT, with the alcohol dependence/abuse section of the mini international neuropsychiatric interview (MINI) used as the gold standard. To explore the relation between the AUDIT and the MINI the sum of the positive items on the MINI (dependence) as a quantitative variable and as an ordinal parameter were analyzed. From the threshold score found for each scale we proposed intervals of severity of AUDs.

RESULTS

The mean age of the sample (122 males, 42 females) was 46 years. Approximately 12% of the patients were identified with alcohol abuse and 78% with dependence (DSM-IV). Cut points were determined for the AUDIT in order to distinguish mild and moderate dependence from severe dependence. A strategy of intervention based on levels of severity of AUD was proposed.

CONCLUSION

Different thresholds proposed for the CAGE, RAPS4-QF, and AUDIT could be used to guide the choice of intervention for a patient: brief intervention, brief negotiation interviewing, or longer more intensive motivational intervention.

Validating the ability of a single-item assessing drunkenness to detect hazardous drinking

BACKGROUND

To simplify the screening process to identify problem drinking, researchers have developed single-item, quantity-based instruments. Quantity-based items, however, suffer from several limitations.

OBJECTIVE

Determine whether a non-quantity-based single item assessing drunkenness would be able to identify those who exhibited signs of hazardous alcohol use, as determined by Alcohol Use Disorders Identification Test (AUDIT)-C scores.

METHODS

Between September and November of 2011, the alcohol-related behaviors of 1062 self-identified current drinkers were assessed with self-report measures (i.e. AUDIT-C and one item assessing frequency of drunkenness) in addition to corresponding biologic samples (i.e. breath alcohol concentration (BrAC) samples). We assessed the concurrent validity of the single item to identify hazardous alcohol use established via gender-based AUDIT-C thresholds. Convergent validity of the single-item was assessed by determining its relationship to BrAC levels.

RESULTS

The single item accounted for 0.791 of the area under the received operating characteristics curve for hazardous alcohol use (p < 0.001). When employing a cut-off of 1, the single-item question was 95.9% sensitive in identifying hazardous alcohol use.

CONCLUSION

The results reported herein highlight the validity (both concurrent and convergent) and potential utility of a non-quantity-based single-item alcohol screen for assessing drunkenness. Additional research is warranted to confirm the utility of this one-item drunkenness measure to capture risk of injury and hazardous drinking.

A Validation Study of the Brief Alcohol Use Disorder Identification Test (AUDIT): A Brief Screening Tool Derived from the AUDIT

Background

The prevalence of alcohol use disorder (AUD) is very high in Korea. To identify AUD in the busy practice setting, brevity of screening tools is very important. We derived the brief Alcohol Use Disorders Identification Test (AUDIT) and evaluated its performance as a brief screening test.

Methods

One hundred male drinkers from Kangbuk Samsung Hospital primary care outpatient clinic and psychiatric ward for alcoholism treatment completed questionnaires including the AUDIT, cut down, annoyed, guilty, eye-opener (CAGE), and National Alcoholism Screening Test (NAST) from April to July, 2007. AUD (alcohol abuse and dependence), defined by a physician in accordance with Diagnostic and Statistical Manual of Mental Disorders-IV, was used as a diagnostic criteria. To derive the brief AUDIT, factor analysis was performed using the principal component extraction method with a varimax rotated solution. Receiver operating characteristic (ROC) curve analysis was performed to investigate the discrimination ability of the brief AUDIT. Areas under the ROC curve were compared performance of screening questionnaires with 95% confidence intervals.

Results

The derived brief AUDIT consists of 4 items: frequency of heavy drinking (item 3), impaired control over drinking (item 4), increased salience of drinking (item 5), and alcohol-related injury (item 9). Brief AUDIT exhibited an AUD screening accuracy better than CAGE, and equally to that of NAST. Areas under the ROC curves were 0.87 (0.80-0.94), 0.76 (0.66-0.85), and 0.81 (0.73-0.90) for the brief AUDIT, CAGE, and NAST for AUD, and 0.97 (0.95-0.99), 0.93 (0.88-0.98) and 0.93 (0.88-0.98) for alcohol dependence.

Conclusion

The new brief AUDIT seems to be effective in detecting male AUD in the primary care setting in Korea. Further evaluation for women and different age groups is needed.

Alcohol misuse and multiple sexual partners

INTRODUCTION

We examine the association between self-reported alcohol misuse and alcohol use within 2 hours of having sex and the number of sexual partners among a sample of African-American and Latino emergency department (ED) patients.

METHODS

Cross-sectional data were collected prospectively from a randomized sample of all ED patients during a 5-week period. In face-to-face interviews, subjects were asked to report their alcohol use and number of sexual partners in the past 12 months. Data were analyzed using multiple variable negative binomial regression models, and effect modification was assessed through inclusion of interaction terms.

RESULTS

The 395 study participants reported an average of 1.4 (standard error = 0.11) sexual partners in the past 12 months, 23% reported misusing alcohol, and 28% reported consuming alcohol before sex. There was no statistically significant association between alcohol misuse and the number of sexual partners; however, alcohol before sex was associated with a larger number of sexual partners in the past year. Moreover, among those who misused alcohol, participants who reported alcohol before sex were 3 times more likely to report a higher number of sexual partners (risk ratio = 3.2; confidence interval [CI] =1.9-5.6). The association between alcohol use before sex and number of sexual partners is dependent upon whether a person has attributes of harmful drinking over the past 12 months. Overall, alcohol use before sex increases the number of sexual partners, but the magnitude of this effect is significantly increased among alcohol misusers.

CONCLUSION

Alcohol misusers and those who reported having more than 1 sexual partner were more likely to cluster in the same group, ie, those who used alcohol before sex. Efforts to reduce the burden of sexually transmitted diseases, including human immunodeficiency virus, and other consequences of risky sexual behavior in the ED population should be cognizant of the interplay of alcohol and risky sexual behaviors. EDs should strive to institute a system for regular screening, brief intervention, and referral of at-risk patients to reduce negative consequences of alcohol misuse, including those of risky sexual behaviors.

CAGE, RAPS4, RAPS4-QF and AUDIT screening tests for men and women admitted for acute alcohol intoxication to an emergency department: are standard thresholds appropriate?

AIMS

A number of screening instruments are routinely used in Emergency Department (ED) situations to identify alcohol-use disorders (AUD). We wished to study the psychometric features, particularly concerning optimal thresholds scores (TSs), of four assessment scales frequently used to screen for abuse and/or dependence, the cut-down annoyed guilty eye-opener (CAGE), Rapid Alcohol Problem Screen 4 (RAPS4), RAPS4-quantity-frequency and AUD Identification Test (AUDIT) questionnaires, particularly in the sub-group of people admitted for acute alcohol intoxication (AAI).

METHODS

All included patients [AAI admitted to ED (blood alcohol level ≥0.8 g/l)] were assessed by the four scales, and with a gold standard (alcohol dependence/abuse section of the Mini International Neuropsychiatric Interview), to determine AUD status. To investigate the TSs of the scales, we used Youden's index, efficiency, receiver operating characteristic (ROC) curve techniques and quality ROC curve technique for optimized TS (indices of quality).

RESULTS

A total of 164 persons (122 males, 42 females) were included in the study. Nineteen (11.60%) were identified as alcohol abusers alone and 128 (78.1%) as alcohol dependents (DSM-IV). Results suggest a statistically significant difference between men and women (P < 0.05) in performance of the screening tests RAPS4 (≥1) and CAGE (≥2) for detecting abuse. Also, in this population, we show an increase in TSs of RAPS4 (≥2) and CAGE (≥3) for detecting dependence compared with those typically accepted in non-intoxicated individuals. The AUDIT test demonstrates good performance for detecting alcohol abuse and/or alcohol-dependent patients (≥7 for women and ≥12 for men) and for distinguishing alcohol dependence (≥11 for women and ≥14 for men) from other conditions.

CONCLUSION

Our study underscores for the first time the need to adapt, taking into account gender, the thresholds of tests typically used for detection of abuse and dependence in this population.

The alcohol use disorders identification test: reliability study of the Japanese version

Alcohol abuse is recognized as a major health issue, and early detection of alcohol abuse is very important. The alcohol use disorders identification test (AUDIT) has been widely used as a specific tool for its detection. We conducted a cross-sectional survey of Japanese male workers to validate the Japanese version of this test. The Japanese version of AUDIT also contains 10 questions. A score greater than or equal to 11 was considered as indicative of serious alcohol abuse or dependence. A total of 168 subjects took part in the survey, and 145 of these subjects sent in their responses to the questionnaire. Among these 145 subjects, there were 136 men. The average age of these male subjects was 38.2 years (±9.9). Among the 136 male subjects, 113 returned completely filled-in questionnaires. There were no significant differences in the mean values of the AUDIT score, short version of AUDIT (AUDIT-C) score, or age between the subjects who did or did not indicate their names in the questionnaire. The internal reliability (Cronbach alpha) of AUDIT was 0.67 for the total subject population and 0.45 for the subjects who indicated their names in the questionnaire (n=69). Cronbach's alpha of AUDIT-C was 0.51 for the total subject population and 0.43 for the subjects who indicated their names in the questionnaire. The Spearman's rho between AUDIT and AUDIT-C was 0.92 (P<.01), and the percentage of subjects with an AUDIT score greater than or equal to 11 was 8.0% (9/113). Thus, the Japanese version of AUDIT showed satisfactory internal reliability. AUDIT is easy to use and is useful for the detection of alcohol-related problems in occupational workers.

Screening, brief intervention, and referral to treatment (SBIRT): 12-month outcomes of a randomized controlled clinical trial in a Polish emergency department

BACKGROUND

 A randomized controlled trial of screening, brief intervention, and referral to treatment (SBIRT) among at-risk (based on average number of drinks per week and drinks per drinking day) and dependent drinkers was conducted in an emergency department (ED) among 446 patients 18 and older in Sosnowiec, Poland.

METHODS

Patients were recruited over a 23-week period (4:00 pm to 12:00 midnight) and randomized to 1 of 3 conditions: screened-only (n = 147), assessed (n = 152), and intervention (n = 147). Patients in the assessed and intervention conditions were blindly reassessed via a telephone interview at 3 months, and all 3 groups were assessed at 12 months (screened-only = 92, assessed = 99, and intervention = 87).

RESULTS

No difference was found across the 3 conditions in at-risk drinking at 12 months, as the primary outcome variable, or in decrease in the number of drinks per drinking day, with all 3 groups showing a significant reduction in both. Significant declines between baseline and 12 months in secondary outcomes of the RAPS4, number of drinking days per week, and the maximum number of drinks on an occasion were seen only for the intervention condition, and in negative consequences for both the assessment and intervention conditions.

CONCLUSIONS

Data suggest that improvements in drinking outcomes found in the assessment condition were not because of assessment reactivity, with both the screened and intervention conditions demonstrating greater (although nonsignificant) improvement than the assessed condition. Only those in the intervention condition showed significant improvement in all outcome variables from baseline to 12-month follow-up. Although group by time interaction effects were not found to be significant, these findings suggest that declines in drinking measures for those receiving a brief intervention can be maintained at long-term follow-up.

Psychometric properties of alcohol screening tests in the emergency department in Argentina, Mexico and the United States

The objective of this article is to report psychometric characteristics of the AUDIT, CAGE, RAPS4, and TWEAK and to compare them across three countries: Argentina, Mexico, and the United States which used a similar protocol and methodology. Probability samples of patients 18 years and older were drawn from emergency departments in Mar del Plata, Argentina (n=780), Pachuca, Mexico (n=1624) and Santa Clara, U.S. (n=1220). Concurrent validity was assessed by comparing their performance against a diagnosis of alcohol dependence (DSM-IV) obtained through the Composite International Diagnostic Interview, and for the briefer measures, also by their correlation with the AUDIT. The internal consistency of the CAGE, RAPS4, and TWEAK scores was estimated by the KR-20 formula and by Cronbach's Alpha for the AUDIT. Corrected item-total correlation and D-values were used as item discrimination measures. In Argentina and Mexico the AUDIT and the RAPS4 showed the highest validity. Reliability of all instruments was higher in the US than in Argentina or Mexico. In all three countries, reliability of the TWEAK was lowest, while the AUDIT was highest. With a few exceptions, all items showed good discrimination powers.

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.

Alcohol and injury in Poland: review and training recommendations

Background

Alcohol plays a significant role in accidents, injuries, and their outcomes. According to the World Health Organization (WHO), there are 76.3 million people with alcohol use disorders worldwide; in 2000, 1.8 million deaths and loss of 58.3 million disability-adjusted life years were attributed to alcohol.

Methods

Although the association between alcohol consumption and trauma-related morbidity and mortality is well-documented, particularly in the US, there is much less information on trauma and alcohol in Poland, a country undergoing unprecedented economic and cultural changes stemming from entry into the European Union (EU) in the midst of a global recession.

Results

Injury is the third leading cause of death in Poland. Rates for all injuries in Poland are higher than in the rest of the EU. Alcohol is one of the greatest risk factors for disease and injury among men and one of the top ten health and injury risk factors for women. In this paper we review the last 10 years of research on injury and alcohol in Poland.

Conclusion

Recommendations are provided for next steps with regard to training health care professionals in emergency medical settings to address this serious and growing problem.

Validity study of Kessler's psychological distress scales conducted among patients admitted to French emergency department for alcohol consumption-related disorders

BACKGROUND

Alcohol-related disorders (ARD) encountered in emergency departments (ED) have a high prevalence and are underestimated. It is necessary to provide professionals with a tool to identify patients in whom there is a risk that alcohol-related and mental health problems may be associated. Kessler's K6/10 psychological distress scales are fast, easy-to-use, and have been shown to achieve a good performance in the identification of psychological distress associated with ARD.

AIM

The aim of this study was to evaluate the psychometric properties of the Kessler scales, version 6 and 10, with a sample of patients admitted to EDs for alcohol consumption.

METHODS

On the day after their admission, with a zero "blood" alcohol concentration, 71 patients were randomly assigned to be assessed using 6 or 10 items version. The internal consistency and factor structure of the K6/10 versions were examined. Convergent validity was measured using the Hospital Anxiety and Depression Scale (HADS) and the Hamilton Depression Rating Scale (HDRS).

RESULTS

The prevalence of psychological distress in our sample was approximately 60%. The selected threshold scores were 10 for K6 (Sensitivity: 0.92; Specificity: 0.62) and 14 for K10 (Sensitivity: 0.95; Specificity: 0.54). The Cronbach coefficients for K6 and K10 were 0.76 and 0.84, respectively. The factor analyses indicated the multidimensional nature of K6/10. The 2 versions, containing 6 and 10 items respectively, correlated better with the HADS (0.83 and 0.70, respectively) than with the HDRS (0.51 and 0.49, respectively). The areas under the ROC Curve indicated a high level of accuracy for both the K6 (0.87) and the K10 (0.77). The difference was not statistically significant.

CONCLUSIONS

This study confirms the good psychometric characteristics of Kessler's psychological distress scale. Even though similar performances were observed for K6/10, the brevity of the K6 makes it more suitable for use in EDs.

Screening, brief intervention, and referral to treatment (SBIRT) in a Polish emergency department: three-month outcomes of a randomized, controlled clinical trial

OBJECTIVE

A randomized, controlled trial of screening, brief intervention, and referral to treatment (SBIRT) for drinking and related problems among at-risk and dependent drinkers was conducted in an emergency department (ED) in Sosnowiec, Poland, among patients ages 18 years and older.

METHOD

Data were collected over a 23-week period, from 4:00 PM to midnight, and resulted in 446 patients being recruited into the study (90% of those who screened positive) and randomized to three conditions following a two-stage process: screened only (n = 147), assessed (n = 152), and received intervention (n = 147). Patients in the assessment (85%) and intervention (83%) conditions were blindly reassessed at 3 months via a telephone interview.

RESULTS

At 3-month follow-up, both groups showed significant decreases in the proportion who were positive for at-risk drinking, the primary outcome variable. Both groups also showed significant decreases in drinking days per week, drinks per drinking day, maximum drinks per occasion, and negative consequences of drinking. Using analysis of covariance to control for baseline measures and demographic characteristics, no difference in outcome measures was found between intervention and assessment conditions. Subgroup analysis found some significant interactions between intervention and secondary outcomes.

CONCLUSIONS

Although the main findings were similar to those from other brief-intervention studies in Western cultures, findings here also suggest that intervention may have differential benefits for specific subgroups of patients in the ED, an area of research that may warrant additional study of brief intervention in the ED setting.

Detecting alcohol-related problems in developing countries: a comparison of 2 screening measures in India

BACKGROUND

There is inadequate recognition of alcohol misuse as a public health issue in India. Information on screening measures is critical for prevention and early intervention efforts. This study critically evaluated the full and shorter versions of the AUDIT and RAPS4-QF as screening measures for alcohol use disorders (AUDs) in a community sample of male drinkers in Goa, India.

METHODS

Data from male drinking respondents in a population study on alcohol use patterns and sexual risk behaviors in randomly selected rural and urban areas of North Goa are reported. Overall, 39% (n = 743) of the 1899 screened men, age 18 to 49, reported consuming alcohol in the last 12 months. These current drinkers were administered the screening measures as part of detailed interviews on drinking patterns and AUD symptoms. Receiver Operating Characteristic (ROC) analysis was conducted for each combination of screening measure and criterion (alcohol dependence or any AUD). Reliability and correlations among the 4 measures were also examined.

RESULTS

All 4 measures performed well with area under the curves of at least 0.79. The full screeners that included both drinking patterns and problem items (the AUDIT and the RAP4-QF) performed better than their shorter versions (the AUDIT-C and the RAPS4) in detecting AUDs. Performance of the AUDIT and RAPS4-QF improved with lowered and raised thresholds, respectively, and alternate cut-off scores are suggested. Scores on the full measures were significantly correlated (0.80). Reliability estimates for the AUDIT measures were higher than those for the RAPS4 measures.

CONCLUSIONS

All measures were efficient at detecting AUDs. When screening for alcohol-related problems among males in the general population in India, cut-off scores for screeners may need to be adjusted. Selecting an appropriate screening measure and cut-off score necessitates careful consideration of the screening context and resources available to confirm alcohol-related diagnoses.

Alcohol and injuries: a review of international emergency room studies since 1995

This paper provides a review of emergency room (ER) studies on alcohol and injury, using representative probability samples of adult injury patients, and focuses on the scope and burden of the problem as measured by estimated blood alcohol concentration (BAC) at the time of the ER visit, self-report drinking prior to injury, violence-related injury and alcohol use disorders. A computerized search of the English-language literature on MEDLINE, PsychINFO and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Alcohol and Alcohol Problems Science Database (ETOH) was conducted for articles published between 1995 and 2005, using the following key descriptors: (1) emergency room/emergency department/accident and emergency, (2) alcohol/drinking and (3) injuries (intentional and unintentional). Findings support prior reviews, with injured patients more likely to be positive for BAC and report drinking prior to injury than non-injured, and with the magnitude of the association substantially increased for violence-related injuries compared to non-violence-related injuries. Indicators of alcohol use disorders did not show a strong association with injury. Findings were not homogeneous across studies, however, and contextual variables, including study-level detrimental drinking pattern, explained some of the variation. This review represents a broader range of ER studies than that reported previously, across both developed and developing countries, and has added to our knowledge base in relation to the influence of contextual variables on the alcohol-injury relationship. Future research on alcohol and injury should focus on obtaining representative samples of ER patients, with special attention to both acute and chronic alcohol use, and to organisational and socio-cultural variables that may influence findings across studies. In-depth patient interviews may also be useful for a better understanding of drinking in the injury event and associated circumstances.

SCREENING, BRIEF INTERVENTION AND REFERRAL TO TREATMENT (SBIRT) IN A POLISH EMERGENCY ROOM: CHALLENGES IN CULTURAL TRANSLATION OF SBIRT

A randomized clinical controlled trial of screening, brief intervention and referral to treatment (SBIRT) for drinking and related problems among at-risk and dependent drinkers, using nurse interventionists, was undertaken in an emergency room (ER) in Sosnowiec, Poland, the first level-one trauma center in that country. This study was the first outside of the U.S. to test protocols developed in a 14-site collaborative SBIRT study. Because Poland has both a pattern of heavy drinking and a highly accessible specialized alcohol treatment system, it offered a key setting for cultural translation of SBIRT to the international context of a new and emerging health care system. It also offered the opportunity to test the effectiveness of SBIRT with both at-risk and dependent drinkers, and to test the feasibility of using ER nursing staff to provide the brief intervention, serving as a potential model for ongoing implementation of SBIRT in ER settings. Findings suggest that the U.S.-based SBIRT protocols can be successfully translated to other cultures, and that nurses can be successfully trained to provide brief intervention for problem drinking in the ER setting.

Paradoxical increase of positive answers to the Cut-down, Annoyed, Guilt, Eye-opener (CAGE) questionnaire during a period of decreasing alcohol consumption: results from two population-based surveys in Ile-de-France, 1991 and 2005

AIMS

To describe trends of responses to the Cut-down, Annoyed, Guilt, Eye-opener (CAGE) questionnaire during a period of declining alcohol consumption, in a country with no temperance history.

DESIGN

Two random-sample surveys, conducted in 1991 and 2005, respectively.

SETTING

The adult population of Ile-de-France.

PARTICIPANTS

A total of 1183 subjects in 1991 and 5382 subjects in 2005.

MEASUREMENTS

Responses to CAGE questions, obtained by face-to-face interviews in 1991 and by telephone in 2005.

RESULTS

were standardized on the 2005 population structure.

FINDINGS

The proportion of subjects giving at least two positive answers has increased by 4.2 times; the biggest increase was observed for the Guilt question (4.8 times) and the smallest for the Eye-opener question (2.6 times). Several increases were higher for women than for men: 12.9 times versus 3.3 times for two or more positive answers, 9.8 times versus 3.8 times for the Guilt question. Increases did not vary consistently by age.

CONCLUSION

These paradoxical trends do not support the use of CAGE in general population surveys. They confirm previous reports suggesting that CAGE was sensitive to community temperance level. They might reflect the emergence of a temperance movement in France, with stronger impact among women. This movement might be responsible for the fall in alcohol consumption.

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.

Effectiveness of Structured Questionnaires for Screening Heavy Drinking in Middle-Aged Women

BACKGROUND

There is a need for an effective and feasible alcohol screening instrument. The aim of the study was to evaluate how the abbreviated versions of the Alcohol Use Disorders Identification Test (AUDIT) questionnaire perform in comparison with the original AUDIT and what the optimal cutoffs are when screening for heavy drinking among women.

METHODS

All the 40-year-old women in the city of Tampere, Finland, are invited yearly for a health screening. From 1 year, data from 894 women (response rate 68.2%) invited for a health screening were utilized in the study. The original 10-item AUDIT, AUDIT-C, Five Shot, AUDIT-PC, AUDIT-3, AUDIT-QF, and CAGE were evaluated against the Timeline Followback. Consumption of at least 140 g of absolute ethanol per week on average during the past month was considered heavy drinking.

RESULTS

In the Timeline Followback, the mean+/-SD weekly reported alcohol consumption was 45+/-67 g (range 0-936 g) of absolute ethanol. Of the women, 6.2% (55/894) were heavy drinkers. The optimal combination of sensitivity and specificity was reached for the AUDIT with cutoff > or =6, for the AUDIT-C with cutoff > or =5, for the Five Shot with cutoff > or =2.0, for the AUDIT-PC with cutoff > or =4, and for the AUDIT-QF with cutoff > or =4. When choosing the optimal cutoffs, the AUDIT-C, the Five Shot, the AUDIT-PC, and the AUDIT-QF performed as well as the 10-item AUDIT. With these cutoffs, sensitivities were 0.84 to 0.93 and specificities were 0.83 to 0.90. The AUDIT-3 and the CAGE did not perform as well as the other questionnaires.

CONCLUSIONS

The 10-item AUDIT, AUDIT-C, Five Shot, AUDIT-PC, and AUDIT-QF seem to be equally effective tools in screening for heavy drinking among middle-aged women. However, their applicability is achieved only if the cutoffs are tailored according to gender.

Single question about drunkenness to detect college students at risk for injury

OBJECTIVES

To examine the frequency of injuries reported by college students who replied affirmatively to the question, "In a typical week, how many days do you get drunk?"

METHODS

In Fall 2003, a Web-based survey was administered to a stratified random sample of 3,909 college students from ten North Carolina (NC) universities. Students answered questions regarding alcohol use and its consequences. Data were analyzed using multiple logistic regression, controlling for within-school clustering of drinking behaviors and adjusting for other significant covariates. Adjusted odds ratios (AORs) and 95% confidence intervals (CI) were calculated for significant predictors (p < 0.05).

RESULTS

Two thousand four hundred eighty-eight students reported that they are current drinkers; 1,353 (54.4%) reported getting drunk at least once in a typical week. Compared with students who did not report getting drunk at least once a week, these students had higher odds of being hurt or injured at least once as a result of their own drinking (AOR = 4.97; 95% CI = 3.47 to 7.09), experiencing a fall from a height that required medical treatment (AOR = 2.16; 95% CI = 1.36 to 3.43), and being taken advantage of sexually as a result of another's drinking (AOR = 2.59; 95% CI = 1.72 to 3.89). Students who reported getting drunk at least one day in a typical week also were more likely to cause an injury requiring medical treatment to someone else. They had higher odds of causing injury in an automobile crash (AOR = 1.84; 95% CI = 1.01 to 3.40), of causing a burn that required medical treatment (AOR = 2.85; 95% CI = 1.51 to 5.39), and of causing a fall from a height that required medical treatment (AOR = 2.02; 95% CI = 1.01 to 4.04). Getting drunk was a better indicator of "self-experienced injury" and of "injury caused to someone else" than was binge drinking, for all outcomes (p < 0.05).

CONCLUSIONS

The single question, "In a typical week, how many days do you get drunk?" identifies college students who are at higher than normal risk of injury as a result of their own drinking and the drinking of others. Future research should assess this question's effectiveness as a screening tool in campus health centers and in emergency departments.