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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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