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Problem Drinking A comparison of different screening tests and why the family physician should take time to screen for substance abuse Charles Popkin Centreville, Mississippi Preceptors Drs. Dick & Rich Field Definitions of Problem Drinking Alcohol Dependence (alcoholism)- involves impaired control over drinking, manifested by physiological addiction to alcohol and/or serious disturbances of health, work, social and/or recreational activities or other areas of functioning related to alcohol use (DSM IV 1994) Alcohol Abuse (harmful drinking)- involves serious disturbances of health, work, social and/or recreational activities or other areas of functioning related to alcohol use, without satisfying criteria for alcohol dependence (DSM IV 1994). Hazardous Use- incorporates binge or heavy chronic drinking, places asymptomatic drinkers at risk for future health problems (USPTF 1996) Relevance to the Population Preceptor Community: Centreville, Mississippi Alcohol and the Centreville ER: • Domestic disputes • 4 wheeler accidents • MVA’s • Epilepsy patient who drank heavily and forgot to take meds • Chronic alcoholic presenting with weakness, ataxia and parasthesias Relevance to Family Practice Discussions about alcohol use can be uncomfortable, and to be most effective they often require…. • A long term, trusting relationship with the patient • Knowledge of patient’s family and social history which might reveal strong risk factors for the patient to abuse alcohol • Many opportunities to build on discussions with consecutive office visits • Since substance use disorders are often chronic conditions that progress slowly over time, family physicians are in an ideal position to screen for alcohol and monitor each patient's status The family physician is well suited to fulfill these requirements! Method to gather info • OVID- used Cochrane DSR, ACP Journal Club and DARE databases Keyword searches: Alcoholism, screening, and interventions • PubMed-used Medline 1966-2003 database Keyword search: CAGE + RAPS4 (questionnaires) and Alcohol USPTF website- searched HSTAT database Keyword search- alcohol and screening- Result was Treatment Improvement Protocol #24 • Two meetings with Dr. Don Gallant, Professor Emeritus Department of Psychiatry, Tulane University School of Medicine. National Expert on Alcohol addiction • Two meetings of Alcoholics Anonymous outside McComb, Mississippi Problems Addressed • Determine why it is important for family practice physicians to screen patients for alcoholism • Determine the best method to screen patients for problem drinking • Determine how patients perceive discussions about problem drinking with their primary care physician Alcohol’s Impact by the Numbers • Alcohol-related disorders occur in up to 26 percent of general medical clinic patients, a prevalence rate similar to those for such other chronic diseases as hypertension and diabetes (Fleming and Barry, 1992). • There were 26,552 deaths in the United States from Chronic Liver Disease and Cirrhosis, the 12th leading cause of death in the United States (National Vital Statistics Report, 2000) • 32 million Americans (15.8 percent of the population) had engaged in binge or heavy drinking (five or more drinks on the same occasion at least once in the previous month) (Substance Abuse and Mental Health Services Administration, 1996) Prevalence of Problem Drinking in Primary Care Manwell, L.; Fleming, M.F.; Barry, K.; and Johnson, K. Tobacco, alcohol, and drug use in a primary care sample: 90 day prevalence and associated factors. Journal of Addictive Diseases, in press. Alcohol’s Economic Impact • Every man, woman, and child in America pays nearly $1,000 annually to cover the costs of unnecessary health care, extra law enforcement, motor vehicle crashes, crime, and lost productivity due to substance abuse (Institute for Health Policy, 1993). • A true estimate of the total economic impact of alcohol is difficult to gauge. The costs to abusers, their families, and society at large, are indisputably enormous and encompass health care costs, premature mortality, workers' compensation claims, reduced productivity, crime, suicide, domestic violence, and child abuse. Why do we need to screen? Screening is the application of a simple test to determine if a patient has a certain condition. For screening to be meaningful in the primary care setting, the particular problem: • Must be prevalent within the general population • Must diminish the duration or the quality of life • Must have an effective treatment available that reduces morbidity and mortality when given during the asymptomatic stage of the disease • Must be detectable via cost-effective screening earlier than without screening and must avoid large numbers of false positives or false negatives • Must be detectable and treatable early enough to halt or delay disease progression and thereby improve outcome (U.S. Preventive Services Task Force, 1996; National Institute on Alcohol Abuse and Alcoholism, 1993) Screening for Problem Drinking meets all the above criteria! Why do we need to screen? -ctd • Problem drinking is too prevalent and costly to be ignored. Take the time to screen! Appropriate Screening Methods in the Family Practice Setting • There are four screening tests that are advocated for use in the primary care/ER setting. They are the CAGE, the AUDIT, the RAPS4 and the FAST questionnaires. • Each one has its individual strengths and weaknesses Identifying those at risk • CAGE questionnaire is an good predictor of current and lifetime alcohol dependence, with high sensitivity and specificity • CAGE consists of 4 questions? • Have you ever felt you should Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? • Have you ever felt bad or Guilty about your drinking? • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener) Cut-off or a positive test is > 2 answers of “yes” Fiellin DA, Carrington RM, O’Connor PG, Screening for alcohol problems in primary care: a systematic review. Archives of Internal Medicine 2000:160:1977-1989. OVID DARE 2003 Babor, T.F.; Kranzler, H.R.; and Lauerman, R.J. Early detection of harmful alcohol consumption Comparison of clinical, laboratory, and self-report screening procedures. Addictive Behaviors 14(2):139-157, 1989. . Evidenced Based Medicine • DARE Cochrane review of Alcohol screening tests from a meta-analysis of 27 trials advocated using the CAGE questionnaire for identifying current and lifetime alcohol abuse and dependence • Sensitivity and Specificity of the CAGE were between 43-94% and 70-97% respectively • The concise nature of the CAGE questionnaire followed with questions addressing quantity and frequency of alcohol consumption is pragmatic and recommended for primary care physicians Fiellin DA, Carrington RM, O’Connor PG, Screening for alcohol problems in primary care: a systematic review. Archives of Internal Medicine 2000:160:1977-1989. OVID DARE 2003 AUDIT for screening • More involved then the CAGE questionnaire, it consists of ten questions that address frequency and quantity of drinking, symptoms of dependence, and problems related to alcohol use. • Designed for early identification of hazardous drinking that may lead to alcohol dependence down the line. • Individual answers are scored 0 to 4, with the range of the test 0 to 40. Cut-off or a positive test is > 8 points • Not the screening test of choice for primary care physicians crunched for time. Fiellin DA, Carrington RM, O’Connor PG, Screening for alcohol problems in primary care: a systematic review. Archives of Internal Medicine 2000:160:1977-1989. OVID DARE 2003 Saunders, J.B.; Aasland, O.G.; Babor, T.F.; Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction 88:791-804, 1993. Evidence Based Medicine on AUDIT • DARE Cochrane review of Alcohol screening tests from a meta- analysis of 27 trials advocated using the AUDIT questionnaire for identifying hazardous or harmful drinking • Sensitivity and Specificity of the AUDIT were between 57-97% and 78-96% respectively • The AUDIT is not as specific or sensitive as the CAGE in identifying current or lifetime alcohol abuse or dependence, but does have a role with the primary care physician with extra time concerned about catching hazardous drinking before it escalates to abuse/dependence. Fiellin DA, Carrington RM, O’Connor PG, Screening for alcohol problems in primary care: a systematic review. Archives of Internal Medicine 2000:160:1977-1989. OVID DARE 2003 RAPS4 • Developed due to concern that the CAGE was not validated for women and minorities (general population) (Cherpitrel, Comparison of screening instruments for alcohol problems, 1997) • RAPS4 consists of 4 questions: • During the past year have your felt guilty about drinking? (Remorse) • During the past year has a friend ever told you things you said or did but do not remember? (Amnesia) • During the past year have you failed to do what was normally expected of you? (Perform) • Do you sometimes take a drink in the morning when you first get up? (Starter) Cut-off or a positive test is > 2 answers of “yes” Evidence Based Medicine • RAPS4 was shown to be more sensitive for problem drinking for both males and females in the ER setting than the CAGE. • Important to note that patients were seen in ER and not the clinic of a primary care physician. • RAPS4’s sensitivity can increase even more with the addition of two questions concerning quantity and frequency (QF) • Cherpitrel C, Screening for alcohol problems in the US General Population: Comparison of the CAGE RAPS4 and RAPS4 and RAPSQ4 by gender, ethnicity and service utilization. Alcoholism Clinical and Experimental Research 2002:26(11):1686-1691. For those in a hurry….. • The FAST questionnaire was created by researchers in the UK because of concern that the other tests were too time consuming. • The FAST is administered in two stages, the first of which consists of only 1 question! Stage I How often do you have more than 8 drinks on one occasion (6 if patient is a woman)? -If the patient answers never, the test is over and the patient is not likely to be misusing alcohol -If the patient answers less than monthly, monthly, weekly or daily, proceed to Stage II of the FAST screening test. Hodgson R, Alwyn T, John B. The FAST Alcohol Screening Test. Alcohol Alcohol. 2002 Jan-Feb;37(1):61-6. Stage II of the FAST • How often during the last year have you been unable to remember what happened the night before because of drinking? • How often have you failed to do what was expected of you because of drinking? • In the last year has a family member, friend or doctor told you to cut down on your drinking? The answers to these questions are never, monthly, less than monthly, weekly or daily. Scored from 0 (never) to 4 (daily) A score of above 3 is positive and indicates a high probability of problem drinking! Healthy People 2010 Goals • 26-1 Reduce deaths and injuries caused by alcohol related motor vehicle • 26-2 Reduce cirrhosis deaths • 26-5 Reduce alcohol-related hospital emergency department visits • 26-7 Reduce intentional injuries resulting from alcohol related violence • 26-8 Reduce the cost of lost productivity in the workplace due to alcohol use Patients at the Alcoholics Anonymous in McComb, Mississippi • By taking a couple of minutes, a primary care physician can help identify problem drinking and take the first step towards helping a patient. • This potential to help, however, is largely untapped: Saitz and colleagues found that of a sample of patients seeking substance abuse treatment, 45 percent reported that their primary care physician was unaware of their substance abuse! Saitz, R.; Mulvey, K.P.; Plough, A.; and Samet, J.H. Physician unawareness of serious substance abuse. American Journal of Alcohol Abuse, in press. At the AA meetings in McComb, I asked 14 members if their primary care physician was aware of their alcohol/substance abuse problem, only 3 indicated their primary care physician was aware of their alcohol problem before they went for treatment. Quality of EBM • Cochrane review supports the use of formal screening tests such as the AUDIT and CAGE to increase recognition of alcohol problems in primary care. • Paper supporting the use of RAPS4 was not a RCT and the patients tested were from an ER setting, not primary care clinics/offices. • FAST screening test supporting literature requires future research comparing its efficacy against other accepted screening tools, but holds promise for those physicians on a tight schedule. • Data regarding primary physician knowledge of patients’ substance abuse problems is in press, to appear in the American Journal of Alcohol Abuse. The evidence is not strong and additional work is required to demonstrate this finding, although an informal survey of McComb AA members does support this position. Interpretations and Conclusions • Due to the high prevalence of problem drinking in the primary care setting (up to 26%), the significant health risks that result without treatment (cirrhosis, hypertension, peripheral neuropathy, cardiomyopathy, etc), and its tremendous economic impact, alcohol screening is recommended in the primary care setting. • The literature supports the use of the CAGE and AUDIT to screen patients in primary care. CAGE is better for identifying current and lifetime alcohol abuse/dependence, but the AUDIT for hazardous drinking. The use of RAPS4 should be limited to the ER setting (like Centreville). It has not been proven in the primary care setting. The FAST questionnaire requires additional studies to prove its efficacy. • More important than which test for alcohol screening, the physician decides to use, make sure you ask about alcohol use! As one physician from the USPTF said, “With respect to alcohol abuse, our charge is straightforward: first we must ask something, then we must do something.” Limitations • Time constraints for a in depth discussion • Only spoke with 14 members of the McComb AA about their relationship with their primary care physician. • Many of the Cochrane and other RCT/studies dealing with alcohol screening tests made recommendations based on ER/trauma patients which may not be applicable to the primary care/office setting Application to Preceptor’s Practice • A brochure was developed on Problem Drinking which will help instigate discussion between patients and doctors about alcohol use. • The brochure will be available in the Field Memorial Hospital ER • The brochure gives some facts about alcohol misuse, contains the RAPS4 screening test and provides additional sources for more information (including the number to the Summit, Mississippi AA chapter) How to use in own practice • Being knowledgeable about the alcohol screening tests will be an asset to help identify future patients at risk for problem drinking in future practice • Spending time at AA meetings, sessions with Dr. Gallant and time in the Centreville ER revealed the potential devastation of untreated problem drinking in the lives of the patient and the effect on their family. By applying these screening tests hopefully I will be able to prevent a future patient’s drinking from escalating out of control. Relevant literature • Babor, T.F.; Kranzler, H.R.; and Lauerman, R.J. Early detection of harmful alcohol consumption Comparison of clinical, laboratory, and self-report screening procedures. Addictive Behaviors14(2):139-157, 1989. • Cherpitrel C, Screening for alcohol problems in the US General Population: Comparison of the CAGE RAPS4 and RAPS4 and RAPSQ4 by gender, ethnicity and service utilization. Alcoholism Clinical and Experimental Research 2002:26(11):1686-1691. • Fiellin DA, Carrington RM, O’Connor PG, Screening for alcohol problems in primary care: a systematic review. Archives of Internal Medicine 2000:160:1977-1989. • Fleming M.F. and Barry K.L, Clinical Overview of alcohol and drug disorders. In Fleming M.F. and Barry K.L. eds of Addictive Disorders. Chicago:Mosby Textbook, 1992. p3-21. • Hodgson R, Alwyn T, John B. The FAST Alcohol Screening Test. Alcohol Alcohol. 2002 Jan-Feb;37(1):61-6. • Manwell, L.; Fleming, M.F.; Barry, K.; and Johnson, K. Tobacco, alcohol, and drug use in a primary care sample: 90 day prevalence and associated factors. Journal of Addictive Diseases, in press • Saitz, R.; Mulvey, K.P.; Plough, A.; and Samet, J.H. Physician unawareness of serious substance abuse. American Journal of Alcohol Abuse, in press. • Saunders, J.B.; Aasland, O.G.; Babor, T.F.; Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction 88:791-804, 1993. • U.S. Preventive Services Task Force, 1996 • http://hstat2.nlm.nih.gov/download/553375426949.html (HSTAT - National Library of Medicine) • http://www.cdc.gov/nchs/fastats/alcohol.htm (CDC website on Alcoholism) Thank you • Special thank you to all the Doctors and Nurses in Centreville, Dr. Streiffer for his help with this project and to Dr. Gallant for taking the time to meet with me and share his extensive knowledge of the subject.
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