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Home arrow Education arrow 100 Questions & Answers About Alcoholism

What are the screening tools available for alcoholism, and are they reliable?

To understand the validity and reliability of screening tools, you must understand that they are measured and compared in terms of sensitivity and specificity. Sensitivity refers to the ability to identify correctly those individuals who are true alcoholics in a population. Specificity refers to the ability to correctly identify those individuals who are clearly not alcoholics. Tests that have high sensitivity and specificity are valid and reliable. No test, not even specific laboratory tests, is 100% sensitive and specific. False positives and negatives exist for every test. That does not make them useless. Keep these concepts in mind when considering the use of the various screening tools used.

Several screening tools are available to identify alcoholism. In 1982, the WHO developed the AUDIT, which is an abbreviation for Alcohol Use Disorders Identification Test. It was designed as either a brief structured interview or self-assessment to be incorporated into general health screening or during a general medical history. AUDIT has 92% sensitivity and 94% specificity. This means that it correctly identifies 92 of 100 alcoholics and 94 of 100 nonalcoholics (see Table 4 for the complete screening tool).

Validity the accuracy of the outcome of a test or Instrument (i.e., the extent to which a test or instrument measures what it intends to measure).

Reliability the ability to reproduce the same outcomes upon repeated testing.

Sensitivity probability of a positive test among patients with a particular disease.

Specificity probability of a negative test among patients without disease. A very specific test, when positive, rules In disease.

Because many felt that the AUDIT was too time consuming, shorter versions were developed. These shortened versions, known as the AUDIT-PC, AUDIT-C, and FAST, essentially contain the first three or four questions of the AUDIT. Needless to say, they are not as valid, and thus, they require the person administering the test to question further when a concern is identified. The first question in FAST — "How often do you have eight or more drinks on one occasion?" — correctly identifies up to 70% of hazardous drinkers who answer either weekly or daily/almost daily. Thus, it can be administered rapidly, and one need not ask additional questions unless someone answers the first question as monthly, less than monthly, or never.

Table 4 The AUDIT

The Alcohol Use Disorders Identification Test is the best test for screening because it detects hazardous drinking and alcohol abuse. Furthermore, it has a greater sensitivity in populations with a lower prevalence of alcoholism. One study suggested that questions 1, 2, 4, 5, and 10 were nearly as effective as the entire questionnaire. If confirmed, AUDIT would be easier to administer.

Questions

0 Points

1 Point

2 Points

3 Points

4 Points I

1. How often do you have a drink containing alcohol?

Never

Monthly

or less

2-4 times a month

2-3 times a week

4 or more times a week

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2

3 or 4

5 or 6

7-9

10 or more

3. How often do you have six or more drinks on one occasion?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

4. How often during the past year have you found that you were not able to stop drinking after you had started?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

5. How often during the past year have you failed to do what was normally expected of you because of drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

7. How often during the past year have you had a feeling of guilt or remorse after drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

8. How often during the past year have you been unable to remember what happened the night before because you had been drinking?

9. Have you or has someone else been injured as a result of your drinking?

10. Has a relative, friend, or a doctor or other health care worker been concerned about your drinking or suggested you cut down?

Never

No

No

Less than monthly

Monthly

Yes, but not in the past year Yes, but not in the past year

Weekly

Daily or almost daily

Yes, during the past year Yes, during the past year

Scoring: Less than 10 does not require additional medication.

CAGE is another common screening tool. CAGE is the mnemonic for the four questions asked: (1) Did you ever feel the need to Cut down on your drinking? (2) Have friends or family Annoyed you by criticizing your drinking? (3) Have you ever felt bad or Guilty about your drinking? (4) Have you ever had a drink in the morning, an Eye opener, in order to get rid of a hangover? This was developed in 1974 and focuses on lifetime rather than current drinking. It is the most widely used in clinical practice and takes only a minute to administer. Two positive responses are considered a positive result. Because CAGE does not focus on patterns and amounts of drinking, it does not identify currently hazardous drinking. Sensitivity ranges from 60% to 90% and specificity from 40% to 95%.

In order to avoid the lengthiness of AUDIT and limitations of CAGE, the Five-shot screening tool was developed that incorporated the first two questions of the AUDIT with three questions from the CAGE. This includes two questions regarding frequency and the amount of alcohol with three basic questions from the CAGE and their various responses as noted in Table 5. At a cut off score of 2.5, the Five-shot tool was found to have a sensitivity of 96% to 100% and a specificity of 76%, which provides an overall accuracy of 78%.

Table 5 The Five-shot Questionnaire

Question

Response

Points

How often do you have a drink containing alcohol?

Never

0

Monthly or less often

0.5

2 to 4 times per month

1.0

2 to 3 times per week

1.5

4 or more times per week

2.0

How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2

0

3 or 4

0.5

5 or 6

1.0

7 to 9

1.5

10 or more

2.0

Have people annoyed you by criticizing your drinking?

No

0

Yes

1

Have you ever felt bad or guilty about your drinking?

No

0

Yes

1

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang-over?

No

0

Yes

1

Other scores use a different scoring range for women when the number of drinks typically consumed is considered.

Total score = SUM (points for all 5 questions).

Interpretation:

minimum score: 0

maximum score: 7

A score of 4 or more is seen in male alcoholics.

Performance:

A score of 3.0 was 77% sensitive and 83% specific for moderate or heavy drinking. The overall accuracy was 83%.

A score of 4.0 was 56% sensitive and 94% specific. The overall accuracy was 90%.

A score of 5.0 was 29% sensitive but 98% specific. The overall accuracy was 90%.

MAST, the Michigan Alcohol Screening Test, was developed in 1971 to detect alcohol dependency. The original tool was 25 questions in length, but this too has been modified to provide for more rapid screening. Its major drawback is its emphasis on lifetime drinking rather than current patterns of alcohol use; thus, it is a poor tool for early detection. Its sensitivity is 86% to 98%, and its specificity 81% to 95%.

Primary care physicians have found it difficult to incorporate screening tools into their practices. This occurs for a variety of reasons: Time constraints often preclude their ability to screen every possible problem that may be hidden from them adequately, fears of offending their patients often cause discomfort in broaching the subject, and finally, a sense of helplessness in being able to refer the patient to the appropriate care if the problem is identified. One way around this discomfort is to reframe the questions in as positive and nonthreatening manner as possible. For example, instead of asking a leading question from the CAGE ("you've never tried to cut down on your drinking, have you?"), you ask the more positive question ("you've tried to cut down on your drinking before, right?"), as if to imply we have all tried to cut down on our drinking.

Because a large proportion of traumas are alcohol- related patients, they are first asked to answer a series of questions regarding any history of trauma on their general health questionnaire:

1. Have you had any fractures or dislocations to your bones or joints?

2. Have you been injured in a traffic accident?

3. Have you ever injured your head?

4. Have you ever been injured in a fight or assault?

If the patient answered yes to one or more of these questions, an additional question was asked:

5. Did any of these injuries occur during or after alcohol use?

If the patient answered positively to two or more questions, the physician would then ask about frequency and quantity of alcohol use. If consumption was high, the physician then asked the CAGE questions. This method reduced the number of patients asked about alcohol to one in seven and identified one in four of trauma patients as having an alcohol problem. This screening system correctly identified 70% of alcoholics and was felt to be reasonably unobtrusive. Interestingly, in the primary care setting, the sensitivity and specificity of the various screening tools differ than in the research setting. For example, the CAGE has been found to be only 62% sensitive for males and 54% sensitive for females in the primary care setting. The AUDIT was found to be more sensitive than the CAGE, though still less so than in the research setting. The other downside of the AUDIT is its lengthiness. As a result of these retests, at least in England, the Five-shot was ultimately found to be the quickest and most effective screening tool to administer, with a sensitivity and specificity of 63% and 95%, respectively. What is the utility of screening tools independent of intervention? Screening tools are found to influence patient behavior alone, with reductions in alcohol consumption occurring simply by bringing it to the patient's awareness and attention.

Susan's comment:

Like many of you who read this book, my struggle with my sons addiction to alcohol didn't start when he began to drink. I still say that I wasn't in denial. I really had no idea that he was different — different from all his friends who did all of the same things, or so I thought. Somehow I turned the other way when some signs were revealed. Because his father, my ex- husband, was and still is an active alcoholic, it was easy to believe that all of those empty vodka bottles hidden around the house belonged to him. It has taken me a long time to realize that I wanted to believe the excuses Ben gave me. Actually, he was in denial for a very long time even after I faced the horrible truth. It was a very slow process getting him to "get his arms around" being an alcoholic. For me, not one day goes by that I don't look at other males his age and wonder why my son is totally disabled by something that all of his friends did with no consequence, something that is part of all my extended family's "war" stories, something that society thinks I should be ashamed of and something that may cause this mother to bury her only son.

Everyone who loves an alcoholic has his or her own way of coping. Mine has been to do three things: (1) to see to it that my only son gets every chance to live by any means necessary, (2) to be very forthcoming regarding his condition so that he doesn't ever feel that I am apart of the overwhelming shame I know he feels, and (3) to study alcoholism extensively in an effort to understand "the enemy. " Those things have often resulted in tears, heartbreak, and despair. Most of the time, however, I have felt relief that my son and I were not alone in his suffering. My husband, not Bens father, wishes that I would be much less open about his "problem, " but I function as I must — one day at a time. Incidentally, of the words abuse, addiction, and dependency, I find that the use of "dependency" is the least of the "evils."

Screening tools are found to influence patient behavior alone, with reductions in alcohol consumption occurring simply by bringing it to the patient's awareness and attention.

 
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