Screening and Assessing
I. Learning Objectives
III. Training Materials
This module is based on the work of a number of scientists and clinicians. The clinical recommendations are based on science and the author's clinical experience.
Alcohol-related problems are a leading cause of morbidity in college students. Student health services provide an ideal opportunity to identify and advise young people who are using alcohol above recommended limits. This module reviews what we know about screening and assessment for alcohol problems. The goal of this module is to provide clinicians with protocols and specific questions to detect at-risk, problem, and dependent alcohol use in college students. The information may also be helpful to persons working in college residential settings and for student advisors.
The goal of screening in student health or other college settings is to reduce alcohol-related harm. Abstinence is an unrealistic expectation for many college campuses. Screening students goes beyond simply identifying and referring students who are alcohol-dependent and require referral to a specialized alcohol treatment program. For example, there is a direct dose-response relationship between drinking and a number of alcohol-related consequences. Persons drinking 3-4 drinks per day have a 2- to 3-fold risk for accidents, stroke, liver disease, cancer, and hypertension (Anderson, 1993). This effect is independent of the presence or absence of alcoholism.
One need not be alcohol-dependent to experience a serious life-threatening problem. Examples of such situations include college students who binge drink enough to become comatose and develop fatal respiratory events, students who are involved in motor vehicle crashes, and students who fall off walls or roofs. If we can identify students at greatest risk for alcohol-related harm, we may be able to reduce the estimated 1,400 deaths and 500,000 serious injuries each year (Hingson, 2002).
Definitions and Criteria
Alcohol use disorders include three categories of drinkers: a) at-risk or hazardous drinkers; b) problem drinkers (synonymous terms are alcohol abuse and harmful drinkers); and c) dependent drinkers (synonymous terms are alcoholic or addicted drinkers). The definitions of these terms vary by clinician, scientist, and country, but for the purpose of this paper, we will use the definitions incorporated in the NIAAA publication The Physicians' Guide to Helping Patients with Alcohol Problems (NIAAA, 1995).
At-risk drinkers are defined as: a) young men who drink more than 14 standard drinks per week; b) young women who drink more than 7 standard drinks per week; or c) students who drink more than 3-4 drinks per occasion one or more times per week. At-risk drinkers usually do not have serious alcohol-related problems and are not alcohol-dependent. Rather, students who drink at these levels are at risk for an alcohol-related adverse event such as an accident, injury, unwanted sexual experience, academic problems, relationship issues, and mental health disorders such as depression. A standard drink in the U.S. contains 14 grams of alcohol and is equivalent to a 12-ounce can or bottle of beer, a 5-ounce glass of wine, or one-and-one half ounces of hard liquor.
Problem drinkers (synonymous terms are alcohol abusers and harmful drinkers) are persons who have experienced repeated alcohol-related problems or adverse events (e.g., accident, injury, problems in school, behavioral problems, blackouts, abusive behavior, fines by campus police, and visits to the emergency departments or urgent care.) Many students who abuse alcohol have a series of alcohol-related problems in high school and college. Many of these students are at risk for alcohol dependence and often require counseling and treatment. Problem drinking is common among college students where heavy drinking is the social norm. There is a direct relationship between quantity and frequency of drinking and the development of problem and dependent alcohol use. Up to 60% of students on some college campuses are at-risk drinkers or problem drinkers (O'Malley and Johnston, 2002).
Dependent drinkers are defined as those who are unable to control their alcohol use, have experienced repeated adverse consequences, are pre-occupied with alcohol use, and have evidence of tolerance or withdrawal. Students who are alcohol-dependent usually have difficulty staying in school and frequently drop out for academic and personal reasons. Students at greatest risk for alcohol dependence are those with very high tolerance, those with a family history of alcoholism, students who use alcohol to deal with stress and mental health issues, and those who drink on a daily basis. Alcohol dependence can occur in college students, but in general, students seen for alcohol problems more often meet the criteria for alcohol abuse rather than alcohol dependence as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).
It is important to understand the differences between conducting screening and doing a diagnostic addiction assessment. The goal of screening is to detect possible alcohol problems, or identify those at risk of developing such problems. Screening procedures are usually brief and can be conducted by persons with limited experience in the alcohol and drug area. Screening can occur in any health care setting or as part of a community-based health program. A diagnostic assessment, on the other hand, is used to establish a diagnosis and develop a specific treatment plan. Assessments are generally conducted over multiple visits by an alcohol and drug abuse specialist in a treatment center. Assessments may also be performed at the request of the legal system for persons arrested for drunk driving or other criminal acts. The material presented in this chapter focuses on screening, biological measures, and brief assessment methods clinicians can use in general clinical settings.
Screening for Alcohol Use Disorders
Alcohol screening methods for use in clinical settings include: a) direct questioning by a health care professional; b) self-administered questionnaires using pencil and paper, computer or telephone; and c) laboratory tests. Many of these methods have excellent psychometric properties that are comparable to a single measurement of blood pressure as a screening test for hypertension or a fasting blood glucose test to detect diabetes. While there is limited research on the extent of underreporting of alcohol use among college students, denial and minimization appear to be less common in this population (Harrison and Hughes, 1997). The reliability and validity of screening methods to detect alcohol and drug use varies by the method of administration of the test, the clinical setting, and the student population. There is limited information on the psychometric properties of alcohol screening tests in college populations. Most of the information presented is based on adult samples.
Alcohol screening tests with high specificity and sensitivity in general adult populations include consumption questions, questions on binge drinking, and two instruments called the CAGE and the Alcohol Use Disorders Identification Test (AUDIT.) Please see page 33 to view a copy of the AUDIT. A number of alcohol screening tests designed for specific populations such as adolescents, women, and emergency department subjects are also included. This module also includes a section on assessing students for alcohol-related harm. Students who drink above recommended limits should complete a brief assessment so the clinician can develop a treatment plan.
Consumption questions that focus on frequency, quantity, and binge drinking are widely recommended as initial screening questions for use in clinical settings (NIAAA, 1995; Canning & Kennell-Webb, 1999; Fleming & Graham, 2001).
Frequency: "How many days per week do you drink alcohol?"
A positive screen would include students who drink alcohol every day, men who drink more than 14 drinks per day, women who drink more than 7 drinks per week, and men and women who drink more than 3-4 drinks per occasion.
* Note: While one binge drinking episode may seem normative and part of the college experience, a single event can have serious adverse consequences. The goal of screening is to identify students at risk, even if it means identifying the majority of students on some campuses.
These questions can be incorporated into routine patient care. They are sensitive and specific for the detection of at-risk and problem drinkers. These questions may be less useful in identifying students who are alcohol-dependent. Studies in adult samples suggest persons who are dependent may minimize alcohol use. Consumption questions can help determine the level of risk of alcohol-related health effects in individual students. For example, young men who drink more than 400 grams of alcohol per week (30 standard drinks) have a 5-fold increase of dying from an alcohol-related problem compared to young men who drink less than 100 grams per week (Andreasson, Allebeck, & Romelsjo, 1988). The risk for an alcohol-related adverse event appears dose-related.
CAGE, CUGE and TWEAK
Indirect behavioral questions such as those contained in the CAGE (Ewing, 1984) or its variants, the CUGE and TWEAK (Sokol, Martier & Ager, 1989; Russell, Martier, & Sokol, 1994), were developed to detect alcohol dependence (Saitz, Lepore, Sullivan, Amaro, & Samet, 1999; Chan, Pristach, Welte, & Russell, 1993). The CAGE assesses four areas related to lifetime alcohol use. One or two positive responses is considered a positive test, and you may want to ask additional questions or refer these patients to an alcohol and drug treatment specialist. The CAGE has been found to have poor psychometric properties in African-American and Mexican-American populations (Volk, Steinbauer, & Cantor, 1997).
Like most of the screening instruments reviewed, the sensitivity and specificity of the CAGE varies in different studies, ranging from 60 to 95% in one study to 40 to 95% in another study. The variability of these reports may be related to: (a) different criterion measures used as the "gold standard" for alcoholism; (b) assessment of lifetime use as compared to current use; (c) varying the cutoff score from 1-4 positive responses; and (d) differences in population samples. Its major deficiencies are that it does not assess current problems, levels of alcohol consumption, or binge drinking. Another concern is that women are more likely to answer positively to the "guilt" question, even at lower consumption levels (Cherpital, 2000). Consequently, we recommend that you only use the CAGE along with questions on quantity, frequency, and binge drinking.
A new instrument called the CUGE was developed to detect alcohol use disorders in young adults. The "annoyed" question in the CAGE was replaced by "driving Under the influence". This substitution resulted in a significantly greater sensitivity and area under the curve (ROC analysis) in a sample of 3,564 college students at a Catholic university in Belgium (Aertgeerts et al., 2000).
The TWEAK is a modification of the CAGE that was developed for young women of childbearing age. It substituted a question on tolerance for the question on guilt, modified the question on annoyed, and added a question about amnesia. Using a criteria standard based on a seven-day drinking report of two or more drinks per day around the time of conception, these five items proved more sensitive than the CAGE or the Michigan Alcoholism Screening Test (MAST) in a population of 4,000 primarily inner-city African-American women (Russell et al., 1994).
Single Screening Questions
Simplicity, low cost, and accuracy are important characteristics of effective screening tools. Numerous researchers have tried to develop 1- or 2-question alcohol screening tests. The single question - "How often in the past month have you had 5 or more drinks on one occasion?" was found to have a sensitivity of 62% and a specificity of 92%. This study by Taj, Devera-Sales, and Vinson (1998) used NIAAA criteria for at-risk drinking and DSM-IV criteria for alcohol dependence or abuse as the standard. This may be the best question to use for screening college students.
In another study, Brown, Leonard, and Saunders (1997) found that two questions had a sensitivity of 79% in a large primary care sample: "In the last year, have you ever drank or used drugs more than you meant to?" and "Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?" Another pair of questions with high psychometric properties is: "Have you had a drink in the past 24 hours?" and "Have you ever had a problem with your drinking?"(Cyr & Wartman, 1988). Cherpitel (1997, 2000) developed a four-question alcohol screening questionnaire, the RAPS4 (Rapid Alcohol Problems Screen) for use in emergency department settings.
Interview Techniques To Increase the Accuracy of Self-Report in College Students
While some patients will minimize their alcohol use, especially those who are alcohol-dependent, a number of interview techniques can minimize underreporting. These include asking about alcohol use in the context of other health behaviors, such as smoking, exercise, stress, and depression. Clinicians who ask questions with empathy and interest will illicit more accurate responses about sensitive areas like alcohol use. Other techniques include asking direct questions in a non-judgmental manner and observing non-verbal cues. Asking about family experience with alcohol and parental use may lead to more accurate responses. Specific questions that may elicit more accurate responses at the higher end of alcohol use include:
"While I know you probably don't drink this much every time, what is the most alcohol you ever drank on a single occasion?"
Screening Alcohol Use Disorders in Special Populations
A number of authors have reported that current alcohol screening tests are less sensitive in women. A review of the alcohol screening literature by Bradley, Badrinath, and Bush (1998) found that the CAGE, AUDIT, Skinner's trauma scale (Skinner, Holt, & Schuller, 1984), and the MAST had poorer psychometric properties in women than in men. A series of studies have examined the psychometric properties of screening instruments in special settings and with special populations. Saitz et al. (1999) found the CAGE a useful screening test in a Latino population.
The CRAFFT alcohol-screening test was developed for adolescents. This 9-question test showed strong psychometric properties in a sample of 99 young people between the ages of 14 and 18 (Knight, Shrier, & Bravender, 1999).
Self-Administered Pencil and Paper Alcohol Screening Questionnaires
Another screening approach is the use of self-administered questionnaires. These include the AUDIT (Babor & Grant, 1989; Volk et al., 1997; Steinbauer, Cantor, & Holzer, 1998), the MAST (Selzer, 1971), the SAAST (Self-Administered Alcohol Screening Test) (Swenson, 1975), and instruments that embed alcohol use questions in the context of other health behaviors such as smoking, exercise, and weight (Health Screening Survey) (Fleming, Barry & MacDonald, 1991). The Prime-MD (Spitzer, Williams, & Kroenke, 1994) combines alcohol questions in the context of a screening test to detect depression. These pencil and paper tests can also be used as an adjunct to questions administered by a clinician or administered by a computer in the waiting room. The AUDIT is the test most frequently recommended as a screening test.
A working group of the World Health Organization created the AUDIT as a brief multi-cultural screening tool for the early identification of problem drinkers (rather than persons who would meet criteria for alcohol dependence). They chose questions that discriminated high-risk drinkers in a six-nation study (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993). The AUDIT contains a series of ten questions that include three questions on alcohol consumption, four questions on alcohol dependence symptoms, and three questions about alcohol-related problems. A cut-off score of six to eight is recommended for at-risk drinking in college students and young adults. (Fleming et al, 1991; Barry & Fleming, 1993; Reinert and Allen, 2002).
The sensitivity and specificity of laboratory tests such as the gamma-glutamyl transferase (GGT), Mean Corpuscular Volume (MCV), and Carbohydrate-Deficient Transferrin (CDT) in college students are not known. In general, these lab markers are correlated with daily sustained drinking for a number of years. Fewer than 20% of heavy drinkers in general adult samples have elevated MCV, GGT, and CDT levels. These markers are more sensitive in men than women.
Blood Alcohol Levels (BAL) can be useful in all students seen for trauma or accidents, especially in an acute care setting. All student health centers may want to obtain a breathalyzer to assess BAL. This procedure is inexpensive and provides an immediate result. Urine drug toxicology screens can also provide useful information, as many students who drink above recommended limits also use other substances.
Alcohol Use Disorders Identification Test (AUDIT)
The following questions are about the past year.
**A score of 8 or more is suggestive of at-risk drinking. Patients who score positive on the AUDIT should be assessed for potential alcohol-related problems.
AUDIT Reference: Babor TF, de la Fuente JR, Saunders J, Grant M. AUDIT: The Alcohol use Disorders Identification Tests: Guidelines for use in Primary health Care. Geneva, Switzerland: World Health Organization, 1992.
Recommendations On the Use of Alcohol Screening Questions and Tests
Assessment for Alcohol Abuse or Dependence
There is limited information available on how to conduct an assessment in a general clinical setting once a patient screens positive for a possible alcohol or drug use disorder. This critical issue has received limited attention from researchers and educators. While clinicians may want to refer a patient who screens positive to an alcohol and drug treatment specialist for a full assessment, it is important to try to classify patients as low-risk, at-risk, problem, or dependent drinkers before making a decision on this step.
The NIAAA publication The Physicians’ Guide to Helping Patients with Alcohol Problems (NIAAA, 1995) recommends that an alcohol assessment include a brief review of alcohol-related medical and mental health issues, legal or social problems, behavioral effects, and symptoms of physical dependence.
A number of self-administered pencil and paper assessment instruments can be used to get a better idea of the extent of the alcohol problem and to develop a treatment plan. These include the 25-question MAST, the 12-question Alcohol Dependence Scale (ADS) (Skinner, 1982), and the 35-question Self-Administered Alcohol Screening Test (SAAST) (Swenson & Morse, 1975). These assessment tools can be completed by the patient independently; the physician then reviews the assessment with the patient. Diary cards are another method that may provide more accurate information on recent alcohol use (Watson, 1999). Diary cards have also been widely used in brief intervention studies as a self-monitoring method (Wallace, Cutler, & Haines, 1988; Fleming, Barry & Manwell, 1997; Ockene, Adams, Hurley, Wheeler, & Hebert, 1999).
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