Problem Drinking

1
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

2
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)

3
Relevance to the Population

• Preceptor Community Centreville, Mississippi
• Alcohol and the Centreville ER
• Domestic disputes
• 4 wheeler accidents
• MVAs
• Epilepsy patient who drank heavily and forgot to
  take meds
• Chronic alcoholic presenting with weakness,
  ataxia and parasthesias

4
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 patients 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!

5
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

6
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

7
Alcohols 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)

8
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.
9
Alcohols 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.

10
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!

11
(No Transcript)
12
Why do we need to screen? -ctd

• Problem drinking is too prevalent and costly to
  be ignored. Take the time to screen!

13
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

14
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 gt 2
  answers of yes
• Fiellin DA, Carrington RM, OConnor PG, Screening
  for alcohol problems in primary care a
• systematic review. Archives of Internal Medicine
  20001601977-1989. 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.
• .

15
(No Transcript)
16
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, OConnor PG,
  Screening for alcohol problems in primary care
  a systematic review. Archives of Internal
  Medicine 20001601977-1989. OVID DARE 2003

17
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 gt 8 points
• Not the screening test of choice for primary care
  physicians crunched for time.
• Fiellin DA, Carrington RM, OConnor PG,
  Screening for alcohol problems in primary care a
  systematic review. Archives of Internal Medicine
  20001601977-1989. 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
  88791-804, 1993.

18
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, OConnor PG, Screening
  for alcohol problems in primary care a
• systematic review. Archives of Internal Medicine
  20001601977-1989. OVID DARE 2003

19
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 gt 2 answers of
  yes

20
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.
• RAPS4s 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 200226(11)1686-1691.

21
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-Feb37(1)61-6.

22
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!

23
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

24
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.

25
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.

26
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.

27
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

28
Application to Preceptors 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)

29
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 patients drinking from
  escalating out of control.

30
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 200226(11)1686-1691.
• Fiellin DA, Carrington RM, OConnor PG, Screening
  for alcohol problems in primary care a
  systematic review. Archives of Internal Medicine
  20001601977-1989.
• 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.
  ChicagoMosby Textbook, 1992. p3-21.
• Hodgson R, Alwyn T, John B. The FAST Alcohol
  Screening Test. Alcohol Alcohol. 2002
  Jan-Feb37(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
  88791-804, 1993.
• U.S. Preventive Services Task Force, 1996
• http//hstat2.nlm.nih.gov/download/553375426949.ht
  ml (HSTAT - National Library of Medicine)
• http//www.cdc.gov/nchs/fastats/alcohol.htm (CDC
  website on Alcoholism)

31
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.