Estimating risk of alcohol dependence using alcohol screening scores

doi:10.1016/j.drugalcdep.2009.11.009

Drug and Alcohol Dependence

Volume 108, Issues 1–2, 1 April 2010, Pages 29-36

https://doi.org/10.1016/j.drugalcdep.2009.11.009 Get rights and content

Abstract

Brief alcohol counseling interventions can reduce alcohol consumption and related morbidity among non-dependent risky drinkers, but more intensive alcohol treatment is recommended for persons with alcohol dependence. This study evaluated whether scores on common alcohol screening tests could identify patients likely to have current alcohol dependence so that more appropriate follow-up assessment and/or intervention could be offered. This cross-sectional study used secondary data from 392 male and 927 female adult family medicine outpatients (1993–1994). Likelihood ratios were used to empirically identify and evaluate ranges of scores of the AUDIT, the AUDIT-C, two single-item questions about frequency of binge drinking, and the CAGE questionnaire for detecting DSM-IV past-year alcohol dependence. Based on the prevalence of past-year alcohol dependence in this sample (men: 12.2%; women: 5.8%), zones of the AUDIT and AUDIT-C identified wide variability in the post-screening risk of alcohol dependence in men and women, even among those who screened positive for alcohol misuse. Among men, AUDIT zones 5–10, 11–14 and 15–40 were associated with post-screening probabilities of past-year alcohol dependence ranging from 18 to 87%, and AUDIT-C zones 5–6, 7–9 and 10–12 were associated with probabilities ranging from 22 to 75%. Among women, AUDIT zones 3–4, 5–8, 9–12 and 13–40 were associated with post-screening probabilities of past-year alcohol dependence ranging from 6 to 94%, and AUDIT-C zones 3, 4–6, 7–9 and 10–12 were associated with probabilities ranging from 9 to 88%. AUDIT or AUDIT-C scores could be used to estimate the probability of past-year alcohol dependence among patients who screen positive for alcohol misuse and inform clinical decision-making.

Introduction

Alcohol misuse, which includes the spectrum from drinking above recommended limits (called hazardous or risky drinking) to alcohol dependence, is a leading preventable cause of death and disability worldwide (Ezzati et al., 2002, Mokdad et al., 2004, World Health Organization, 2007). More than 15% of adults drink above recommended limits (Grant et al., 2004), placing them at increased risk for alcohol-related problems, and about a quarter of these adults meet criteria for alcohol dependence (National Institute on Alcoholism and Alcohol Abuse, 2006). The U.S. Preventive Services Task Force (USPSTF) recommends screening and brief counseling interventions in primary care settings to reduce alcohol misuse (U.S. Preventive Services Task Force, 2004) but brief interventions may be less effective for patients with alcohol dependence (Kaner et al., 2007, Moyer et al., 2002). Thus, experts recommend that patients with alcohol dependence be offered referral to specialty addictions treatment or, when referral is not possible, that alcohol dependent patients be managed with repeated primary care interventions (Babor et al., 2001, NIAAA, 2007, Willenbring and Olson, 1999). In addition, patients with alcohol dependence can be offered medications combined with medical monitoring (Anton et al., 2006, NIAAA, 2007, Willenbring, 2007).

Although specialized treatment is recommended for patients with alcohol dependence, there is no practical approach for identifying these patients among those who screen positive for alcohol misuse in routine practice. National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines (National Institute on Alcohol Abuse and Alcoholism et al., 2007) suggest that clinicians ask patients seven questions based on Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria (American Psychiatric Association, 1994) to assess alcohol dependence, but primary care providers may not recall or have easy access to the criteria and often do not have time even for such limited assessments. An alternative approach is to use screening scores to identify patients who are most likely to have alcohol dependence. World Health Organization (WHO) guidelines for the Alcohol Use Disorders Identification Test (AUDIT) suggest four “zones” of scores that indicate increasing levels of alcohol-related risk, with Zones III (scores 16–19) and IV (scores 20–40) suggestive of alcohol dependence (Babor and Higgins-Biddle, 2001). However, to our knowledge these zones have not been validated for improved management of primary care patients. Additionally, comparable risk zones for alcohol dependence have not been proposed using other alcohol screening questionnaires.

Most previous validation studies have evaluated alcohol screening questionnaires as dichotomous screening tests, with the sensitivity and specificity of the target disorder estimated for all scores above a specified screening threshold. In contrast, the present study evaluates ranges of screening scores (“risk zones”) to retain additional diagnostic information provided by the score. The likelihood ratio of a given risk zone incorporates the sensitivity and specificity and similarly provides a means for quantifying diagnostic capacity. Furthermore, likelihood ratios for each risk zone can be used to calculate the post-screening probability that a patient has alcohol dependence in clinical settings with varying overall prevalence rates of alcohol dependence.

The purpose of this study was to empirically identify scores on five commonly recommended alcohol screening tests that indicate a high likelihood of alcohol dependence for men and women. Specifically, we identified risk zones of alcohol screening scores that can help estimate the probability of past-year alcohol dependence among men and women who screen positive for alcohol misuse on the following alcohol screening questionnaires: the 10-item AUDIT (Babor et al., 2001), the 3-item AUDIT-C (Bush et al., 1998b), which consists of the alcohol consumption questions from the AUDIT, two single questions that assess the frequency of episodic heavy drinking, and the widely known CAGE questionnaire (Ewing, 1984), which was developed to identify alcohol use disorders rather than the spectrum of alcohol misuse. We further evaluated the likelihood ratios and post-screening probability of past-year alcohol dependence among men and women in each identified risk zone of each questionnaire, as well as in each of the AUDIT zones previously proposed by the WHO.

Section snippets

Study population

This cross-sectional study used secondary data from a prospective validation study of alcohol screening tests. Study participants were patients with appointments at a family medicine clinic at the University of Texas in Galveston from October 1993 to December 1994. This study was approved by the Institutional Review Boards at Baylor College of Medicine and the University of Washington.

Patients were eligible if they were at least 18 years old, were scheduled to see randomly selected providers at

Results

Of the 1445 patients approached about participating in the study, 21 (1.5%) were not one of the racial/ethnic groups included in the study, 82 (5.7%) refused participation, 9 (0.6%) consented but later withdrew and 14 (1.0%) had incomplete alcohol screening data. The resulting study sample of patients (92.6% of those eligible) included 392 (29.7%) men and 927 (70.3%) women with mean ages of 46 and 42 years, respectively. The racial/ethnic distribution roughly mirrored that of the Galveston

Discussion

This study shows the potential utility of using risk zones of alcohol screening tests to estimate the probability of current DSM-IV alcohol dependence among patients who screen positive for alcohol misuse. In this sample, probability of past-year alcohol dependence varied widely across alcohol screening risk zones above the threshold for alcohol misuse. Among men, at least 75% of those with AUDIT scores 15–40, with AUDIT-C scores 10–12, or who reported 14–30 days of drinking 5 or more drinks in

Role of funding source

This study was supported by resources from the VA Puget Sound Health Care System's Northwest HSR&D Center of Excellence and was funded by National Institute on Alcohol Abuse and Alcoholism (NIAAA) R21AA14672. The Northwest HSR&D Center of Excellence and NIAAA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Contributors

Kathy Bradley, Dan Kivlahan, and Robert Volk contributed to the design of this study, Kathy Bradley wrote the protocol, and Anna Rubinsky conducted the statistical analysis and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

Conflicts of interest

All other authors declare that they have no conflicts of interest.

Acknowledgements

This material is the result of work supported by resources from the Northwest Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System, Seattle, WA. The research reported in this article was supported by National Institute on Alcohol Abuse and Alcoholism R21AA14672.

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Citation Excerpt :
Women self-reported demographic information, alcohol–related symptoms and behaviors, and mental health symptoms, via an automated computer-assisted self-interview (ACASI). The Alcohol Use Disorders Identification Test (AUDIT) (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) provided information on alcohol problem severity, using cut-offs of < 7, 7–12, and ≥ 13 (Rubinsky, Kivlahan, Volk, Maynard, & Bradley, 2010). The MINI-International Neuropsychiatric Interview (M.I.N.I.) DSM-IV (Sheehan et al., 1998) was used to classify individuals as having an alcohol use disorder (AUD) if they scored one or more on the alcohol abuse items and/or three or more on the dependence items.
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^☆: Supplementary information on the data analytic approach used in this study is available with the online version of this paper at doi:xxx/j.drugalcdep.xxx.

^☆☆: Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, University of Washington, Baylor College of Medicine, The University of Texas or National Institute on Alcohol Abuse and Alcoholism.

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Estimating risk of alcohol dependence using alcohol screening scores☆,☆☆

Abstract

Introduction

Section snippets

Study population

Results

Discussion

Role of funding source

Contributors

Conflicts of interest

Acknowledgements

Diagnostic and Statistical Manual of Mental Disorders

Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial

JAMA

Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care

Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population

Arch. Intern. Med.

AUDIT-C as a brief screen for alcohol misuse in primary care

Alcohol Clin. Exp. Res.

Brief approaches to alcohol screening: practical alternatives for primary care

J. Gen. Intern. Med.

Implementation of evidence-based alcohol screening in the Veterans Health Administration

Am. J. Manage. Care

Screening for alcohol abuse using CAGE scores and likelihood ratios

Ann. Intern. Med.

The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test

Arch. Intern. Med.

The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking

Arch. Intern. Med.

New approach to the validity of the alcohol use disorders identification test: stratum-specific likelihood ratios analysis

Alcohol Clin. Exp. Res.

Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach

Biometrics

Likelihood ratios: a real improvement for clinical decision making?

Eur. J. Epidemiol.

Detecting alcoholism: the CAGE questionnaire

JAMA

Selected major risk factors and global and regional burden of disease

Lancet

Letter: Nomogram for Bayes theorem

N. Engl. J. Med.

The efficacy of a brief alcohol intervention combined with %CDT feedback in patients being treated for type 2 diabetes and/or hypertension

J. Stud. Alcohol

Stratum-specific likelihood ratios of two versions of the general health questionnaire

Psychol. Med.

Prevalence of DSM-IV alcohol abuse and dependence, United States, 1992

Alcohol Health Res. World

The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991–1992 and 2001–2002

Drug Alcohol Depend.

The Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reliability of alcohol and drug modules in a general population sample

Drug Alcohol Depend.

The Alcohol Use Disorder and Associated Disabilities Interview Schedule