Screening for alcohol and other drug abuse – includes related questionnaire – Prevention in Clinical Practice
Screening for Alcohol and Other Drug Abuse
Recommendation: All adolescents and adults should be asked to describe their use of alcohol and othe drugs. Routine measurement of biochemical markers and drug testing are not recommended as the primary method of detecting alcohol and other drug abuse in asymptomatic persons. Persons in whom alcohol or other drug abuse or dependence is confirmed should receive appropriate counseling, treatment and referrals. All persons who use alcohol, especially pregnant women, should be encouraged to limit their consumption, and all persons who use alcohol or other intoxicating drugs should be counseled about the dangers of operating a motor vehicle or performing other potentially dangerous activities while intoxicated.
Burden of Suffering
Although the exact prevalence of alcohol and other drug abuse is difficult to measure with certainty, it has been estimated from population surveys that over 11 million Americans meet the diagnostic criteria for abuse or dependence.1 Commonly abused drugs in the United States include ethyl alcohol and illicit drugs, such as cocaine, heroin, marijuana, phencyclidine and methaqualone, as well as amphetamines, benzodiazepines and barbiturates not prescribed by a physician. The prevalence and consequences of abuse vary with each drug.
Alcohol is used by over half of all American adults, but reliable data on the percentage who abuse alcohol are lacking.2 National surveys indicate that 11 percent of American drinkers use alcohol daily; 10 percent report losing control while drinking or admit to dependence on alcohol during the past year, and 8 percent report recent binge drinking (five or more drinks).2,3
It has been estimated that alcohol accounted for over 69,000 deaths in 1980.1 About half of all deaths from motor vehicle crashes, fires, drownings, homicides and suicides are the result of alcohol intoxication.4 In 1987, an estimated 23,630 persons were killed in alcohol-related motor vehicle crashes, accounting for nearly 7 percent of all years of potential life lost in the United States in that year.5
Chronic alcohol abuse often leads to dependence, alcohol withdrawal syndrome, serious medical complications (e.g., hepatitis, cirrhosis, pancreatitis, thiamine deficiency, gastrointestinal bleeding, cardiomyopathy) and certain forms of cancer.4 Over 560,000 hospital admissions in 1982 were for alcohol-related conditions.2 A common complication, cirrhosis, was the ninth leading cause of death in the United States in 1986.6 Excessive use of alcohol during pregnancy can produce the fetal alcohol syndrome,7 which has been estimated to affect about one out of every 750 newborns.8
Social consequences of alcohol and other drug dependence include divorce, unemployment and poverty. It has been estimated that the economic costs of alcohol abuse, including medical treatment, lost productivity and property damage, exceeded $115 billion in 1983.1 An estimated 27 million American children are at risk for abnormal psychosocial development due to the abuse of alcohol by their parents.9
Between 1 and 3 million Americans are thought to be regular users of cocaine.10 Self-administration of this drug can produce sudden death due to cerebral hemorrhage, seizures, arrhythmias, myocardial infarction or respiratory arrest.10 Regular intranasal administration can cause sinus disease and nasal septal perforation; respiratory complications may occur in those who smoke the drug.10 Intravenous use of cocaine is a risk factor for the acquired immunodeficiency syndrome (AIDS) and other medical complications of intravenous drug use. Chronic use can lead to psychologic dependence, and users of “crack,” a popular smokable form of cocaine, can become addicted with their first session.11
Dependence on cocaine produces behavioral effects such as diminished motivation, psychomotor retardation, irregular sleep patterns and other symptoms of depression.12 Use of cocaine during pregnancy may increase the risk of premature labor, placental abruption, intrapartum fetal distress and neonatal complications.13
About 500,000 Americans are addicted to heroin, and more than 2 million use the drug occasionally.14 Mortality among heroin addicts is high (about 10 per 1,000 annually) as a result of overdose, suicide, violence and medical complications such as infectious hepatitis, bacterial endocarditis and pulmonary emboli.14 Infants born of women using narcotics often experience withdrawal symptoms and are possibly at risk of long-term psychologic and behavioral effects.15 Intravenous use of heroin and other drugs is an important risk factor for developing AIDS; transmission of the human immunodeficiency virus (HIV) through contaminated needles accounts for about 25 percent of all AIDS cases.16 There are about 900,000 intravenous drug users in the United States, and it is estimated that in some cities half of the users are infected with HIV.16
Marijuana is smoked regularly by over 10 million Americans.17 As with alcohol and other psychoactive drugs, safe operation of a motor vehicle is compromised when the driver is intoxicated with marijuana.18 In addition, marijuana smoke may contain more carcinogens and tar than tobacco smoke, and thus chronic smokers of cannabis may be at increased risk of pulmonary disease. Other complications of regular use include amotivational syndrome and physical dependence.17,18
DRUG USE IN ADOLESCENTS
The use of drugs by adolescents and young adults is an increasingly serious problem. The leading causes of death at this age–motor vehicle and other unintentional injuries, homicides and suicides–are associated with alcohol and other drug intoxication in about half of the cases.19 Driving under the influence of alcohol is more than twice as common in adolescents as in adults.20 A 1987 survey found that one out of four high school seniors has used an illicit drug other than marijuana in the past year.21 More than 3 percent smoke marijuana and 5 percent drink alcohol daily; 37 percent admit to binge drinking in the past two weeks. Over 4 percent have used cocaine in the past month, and nearly 6 percent admit to having experimented with crack. In addition to the risk of unintentional injuries and medical complications produced by these agents, drug abuse during adolescence and young adulthood can lead to chemical dependence, use of more dangerous drugs, diminished academic performance and limited opportunities for professional and personal growth.22
Efficacy of Screening Tests
The most meaningful indicators of substance abuse (e.g., patterns of drug use, impact on personal relationships, work performance) are difficult to assess accurately during the clinical encounter. Physical findings, such as hepatomegaly and eye signs, cannot be relied on: they are often late manifestations of drug abuse and are not pathognomonic.23 The detection of alcohol and drug abuse by clinicians is often possible only through indirect methods. These include patient descriptions of drug use, screening questionnaires and laboratory analysis of body fluids.
Asking the patient about the quantity and frequency of alcohol and other drug consumption is an important means of detecting abuse and dependence. There are, however, both limitations and variations in the accuracy of patient responses to such questions. While some studies have shown that patient descriptions of alcohol use are accurate,24 such self-reported estimates are not always reliable. Some patients may underestimate drug-using behavior because of denial or forgetfulness. Others may conceal the information for fear of the associated social stigma25 or punitive action by employers and law-enforcement officials.
In one study, the questions “How much drink?” had a sensitivity of less than 50 percent in detecting persons with a drinking problem, when compared with the Michigan Alcoholism Screening Test (MAST).26 Others estimate the sensitivity of historical inquiry to be as low as 10 to 15 percent.27 Such studies, by relying on data from questionnaires examining both past and present drinking behavior as the reference criterion for defining a” true positive,” may provide misleading information about the usefulness of historical questions in assessing current problems. Most authorities agree that the accuracy and clinical value of asking patients about their use of alcohol and other drugs are highly variable and depend on the patient, the clinician and other individual circumstances.28,29
Tjere are s[ecoa; doffoci;toes om pbtaomomg an accurate drug history from certain patients, such as adolescents. It is common at this age to distrust authority figures such as clinicians, and young persons may be especially concerned about disclosure of the information to family members, school officials or the police.30
A second screening method is the questionnaire, which has been most extensively evaluated as a means of detecting alcohol abuse. Examples include the MAST,31 the CAGE questionnaire32 and the Self-Administered Alcoholism Screening Test (SAAST).33 Of these, the most extensively validated instrument is the MAST, which has a reported sensitivity and specificity of 84 to 100 percent and 87 to 95 percent, respectively.31,34,35 This instrument is too lengthy for routine use in primary care settings, however, and shorter questionnaires have been developed. These include the Brief MAST (BMAST) and a questionnaire addressing trauma history,36 but the fourquestion CAGE instrument (Table 1) is the most popular for use in primary care.32 Some studies of this questionnaire have reported excellent sensitivity and specificity (85 to 89 percent and 79 to 95 percent, respectively),25,37,39 but in other studies the reported sensitivity is as low as 49 to 68 percent.40
Inconsistent reports for the CAGE and other questionnaires reflect, in part, different study populations, varying reference criteria for defining problem drinking or alcohol abuse, and confounding variables in published validation studies.41,42 In addition, some questionnaires may be effective in identifying persons with established drinking disorders but may not serve as useful early detection tests because of an inability to detect problem drinking before the development of significant behavioral changes.43 Although there are few reliable questionnaires for the primary detection of abuse of drugs other than alcohol, questionnaires such as the Addiction Severity Index44 are available to help evaluate the treatment needs of patients with signs of drug/alcohol abuse or dependence.
A third screening method for alcohol and other drug abuse is the laboratory analysis of body fluids. Chronic abuse of alcohol, for example, is often associated with elevations in hepatic enzymes and the erythrocyte mean corpuscular volume. These abnormalities do not occur consistently, however, and therefore such biochemical markers serve as poor screening tests.40 The sensitivity of the best marker for alcohol abuse, serum gamma-glutamyl transferase (GGT), has in some studies been reported to be as high as 60 percent.39 In most research, however, estimates range between 30 and 50 percent.27,37,45 GGT also has poor specificity, because it can be elevated by certain medications, trauma, diabetes and heart or kidney disease.46 Thus, the reported false-positive rate is high, ranging between 13 and 50 percent.37,39,47 Through sophisticated statistical analysis, it may be possible to combine the results of more than one biochemical test or to combine biochemical information with interview and questionnaire data to predict alcoholism with greater accuracy, but these techniques remain research tools at this time.40,48,49
Biologic tests for evidence of drugs other than alcohol often only provide evidence of recent drug exposure and thus are of limited value in determining whether the drug is being used chronically or during potentially dangerous activities.50 Since the metabolites of such drugs as cocaine and marijuana can be present in the urine for days to weeks following a single exposure,10,50-52 it is often impossible to determine retrospectively the regularity of drug use, the level of intoxication or whether other persons, such as co-workers or motorists, were endangered by the patient at the time of drug use.
Depending on the drug, the method of analysis and the population being tested, between 5 and 30 percent of positive results are false positives,50,51 owing to sample contamination, cross-reactivity with other drugs and laboratory error.52 Also, a negative test does not rule out drug abuse, since the metabolites may have been excreted or, if custody of the sample has not been monitored, the specimen may have been subject to tampering.52 The results may create personal difficulties for patients. A positive drug screen can affect employment, legal action, insurance coverage and personal relationships.50
Effectiveness of Early Detection
Although early medical intervention is important in treating the systemic complications of acute drug intoxication or chronic abuse, there is less rigorous evidence that early intervention in asymptomatic persons is of benefit. Specifically, it has not been demonstrated in a controlled setting that the detection and treatment of alcohol or other drug abuse through screening of asymptomatic persons can produce a better outcome than conventional treatment after signs and symptoms become apparent.
Some studies, however, support the efficacy of counseling once the signs or symptoms of problem drinking or alcohol abuse are detected. A randomized controlled trial has shown that identification of heavy drinkers followed by counseling and repeated feedback of GGT results can lower the rate of sick absences, hospitalization and mortality from alcohol abuse.53-55 Another randomized trial found that problem drinkers on a medical ward who received counseling by a nurse had lower alcoholic consumption than control subjects when evaluated 12 months later.56 Early intervention for excessive drinking during pregnancy has been shown to be effective in lowering alcohol consumption and neonatal complications.7,57
Alcohol treatment programs and other approaches, such as psychotherapy and disulfiram treatment, can be equally effective in at least some patients.40,58,59 It has been reported that over 60 percent of persons completing organized alcohol treatment programs remain abstinent after leaving them.40,60 However, much of the data on the effectiveness of alcohol treatment programs suffers from important methodologic limitations. Many studies lack proper control groups, and the duration of follow-up is often inadequate to reveal subsequent relapse from abstinence to problem drinking. Participants in voluntary treatment programs often have unique personality characteristics,61-63 and thus the outcome for subjects in studies lacking control groups or randomization may not be applicable to persons unable or unwilling to join.
Finally, since spontaneous remission occurs in as many as 30 percent of alcoholics,64,65 reduced consumption may be inappropriately attributed to the clinical intervention. Surveys of recovered alcoholics suggest that while treatment is of some importance in the recovery process, social pressures represent the principal stimulus to changing drinking behavior.66
DRUGS OTHER THAN ALCOHOL
The evidence is more limited regarding the effectiveness of treatment for the abuse of drugs other than alcohol. Although successful results have been reported for persons addicted to cocaine and other drugs, the evidence is not conclusive.67-69 More data are available on the treatment of heroin dependence, primarily with methadone or naltrexone. Several studies, including a randomized controlled trial, show that heroin addicts who remain in methadone maintenance programs have reduced heroin consumption, lower rates of positve antibodies for the HIV virus, and decreased criminality and unemployment.14,70 Over the short term, methadone treatment is associated with a 95 percent reduction in self-reported heroin use and a 57 to 68 percent reduction in self-reported cocaine use.71
Some persons may switch from heroin to other drugs while receiving treatment. One study found that among cocaine-using heroin addicts in long-term (more than one year) methadone maintenance programs, 26 percent began and 6 percent increased the frequency of cocaine injection after beginning treatment.71 Moreover, selection bias is possible, since many addicts drop out of programs when the methadone dose is lowered or discontinued,14 and many studies rely on imprecise criteria, such as patient self-reports, to measure outcome.72
Recommendations of Others
Most experts agree that clinicians should be alert to the signs and symptoms of alcohol and other drug abuse and should routinely discuss patterns of use with all patients. There are no guidelines, however, on the content of the patient interview, and there are no official recommendations for physicians to routinely use questionnaires or laboratory tests to detect alcohol and other drug abuse in asymptomatic persons.
A workshop sponsored by the National Institute on Alcohol Abuse and Alcoholism recommended that clinicians routinely ask a neutral question about alcohol consumption, followed by completion of the CAGE questionnaire for patients who drink.73
The American Medical Association advises physicians to remain alert to the presenting signs and symptoms of alcoholism and drug abuse and to include an in-depth history of substance abuse as part of a complete health examination.74 The AMA also supports drug testing (in conjuction with rehabilitation and treatment) as part of pre-employment examinations for jobs affecting the health and safety of others, or when there is reasonable suspicion of alcohol or other drug impairment.75 There is a strong consensus among experts that once drug abuse is suspected, further evaluation of the patient and laboratory results is important to discriminate between true cases of abuse and false positives. Once the diagnosis is established, the clinician should either provide or arrange appropriate treatment and counseling for the patient and family.
Recommendations for children and adolescents have been issued by the American Academy of Pediatrics.76 The AAP recommends careful discussion with all adolescents regarding the extent of drug use and regular counseling regarding abstinence from intoxicants when driving. Clinicians should advise parents and children to discuss the proper use of alcohol at teen parties and to recommend alternatives to driving while intoxicated or riding in a vehicle operated by an intoxicated driver. The AAP also advises physicians to counsel parents regarding their own use of alcohol in the home. If problem drinking is discovered in the child, appropriate counseling and referrals for treatment should be provided for the patient and family.76
The U.S. Surgeon General advises health professionals caring for pregnant women or women considering pregnancy to inquire routinely about alcohol consumption, to advise women to abstain from alcoholic beverages during pregnancy and to be aware of the alcohol content of foods and drugs.77
The American College of Obstetricians and Gynecologists recommends counseling pregnant women to avoid alcohol during pregnancy, noting that although moderate drinking may not be harmful to the fetus, the definition of moderate alcohol consumption during pregnancy has not been determined.78
Clinical efforts to detect alcohol and other drug abuse in asymptomatic persons suffer from the lack of a sensitive and specific screening test for use in primary care. Conventional historical questions are not standardized and cannot be relied on to detect all cases of alcohol and other drug abuse. The MAST questionnaire is too lengthy for busy practices, and study results are inconsistent regarding the accuracy of shorter instruments such as the CAGE questionnaire. Laboratory tests lack sensitivity and specificity, and they often provide evidence only of a recent drug exposure, rather than of chronic drug abuse. Even if alcohol or other drug abuse is detected, further research is needed to establish the efficacy of various early treatment strategies in improving prognosis.
Nonetheless, clinicians should pursue this diagnosis because of the enormous burden of suffering associated with abuse and dependence and the central etiologic role of alcohol and other drug abuse in several leading causes of death in the United States. Even if treatment successes are infrequent, the benefits to the population as a whole may be substantial. This is especially the case in adolescents and adults under age 45, for whom motor vehicle and other injuries are the leading causes of death and the years of potential life lost.
Clinicians should routinely ask all adult and adolescent patients to describe their use of alcohol (i.e., wine, beer, liquor) and other drugs, including quantity, frequency and other characteristics of use. Certain questionnaires may be helpful to clinicians in assessing important alcohol use patterns. An affirmative answer to at least two of the four questions in the CAGE instrument,32 for example, may provide useful information on the likelihood of a previous or current problem with alcohol abuse. Discussions with adolescents should be approached with discretion to establish a trusting relationship and to respect the patient’s concerns about the confidentiality of disclosed information.
Routine measurement of biochemical markers, such as serum GGT, and drug testing of urine or other body fluids are not recommended as the primary method of detecting alcohol or other drug abuse in asymptomatic persons. If drug testing is done for other reasons, positive results should be interpreted with an awareness of the pharmacokinetics of the drug and the limitations of the laboratory and analytic method.
Persons in whom drug abuse or dependence is suspected should receive further evaluation to confirm the diagnosis and accuracy of test results and to rule out false positives. Once the diagnosis is confirmed, the clinician should inform the patient of the effects of the drug and should develop a treatment plan for the patient and family that is tailored to the drug of abuse and the needs of the patient. Many patients may benefit from referrals to appropriate consultants and community programs specializing in the treatment of alcohol and other drug dependencies.
All persons who use alcohol should be informed of the health and injury risks associated with alcohol consumption and should be encouraged to limit consumption to moderate intake levels (e.g., fewer than two drinks per day). One drink is defined as 12 ounces of beer, a 5-ounce glass of wine or 1.5 fluid ounces (one jigger) of distilled spirits.
Persons who use alcohol or other psychoactive drugs should also be counseled regarding the dangers of operating motor vehicles and engaging in other potentially dangerous activities when intoxicated, as well as the risks of riding in a vehicle in which the driver is intoxicated. Adolescents and young adults in particular should be encouraged to discuss with their families transportation alternatives for social activities where alcohol and other drugs are used.
Pregnant women should be given information in the first trimester about the harmful effects of alcohol and other drugs on the fetus. They should be advised to drink moderately, if at all, during pregnancy. Intravenous drug users should be referred for treatment and warned against the use of contaminated needles, which can transmit HIV, hepatitis B and other organisms. 1. Kamerow DB, Pincus HA, Macdonald DI. Alcohol abuse, other drug abuse, and mental disorders in medical practice. Prevalence, costs, recognition, and treatment. JAMA 1986;255: 2054-7. 2. Berkelman RL, Ralston M, Herndon J, Gwinn M, Bertolucci D, Dufour M. Patterns of alcohol consumption and alcohol-related morbidity and mortality. MMWR CDC Surveill Summ 1986;35:1SS-5SS. 3. Clark WB, Midanik L. Alcohol use and alcohol problems among U.S. adults: results of the 1979 national survey. In: Alcohol consumption and related problems. Alcohol and health monograph no. 1. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, 1982; DHHS publication no. (ADM) 82-1190. 4. West LJ, Maxwell DS, Noble EP, Solomon DH. Alcoholism. Ann Intern Med 1984;100:405-16. 5. Premature mortality due to alcohol-related motor vehicle traffic fatalities–United States, 1987. MMWR 1988;37:753-5. 6. Advance report of final mortality statistics, 1986. Hyattsville, Md.: Public Health Service, 1988; DHHS publication no. (PHS) 88-1120, (Monthly vital statistics report; vol. 37, no. 6). 7. Rosett HL, Weiner L, Edelin KC. Treatment experience with pregnant problem drinkers. JAMA 1983;249:2029-33. 8. Hanson JW, Streissguth AP, Smith DW. The effects of moderate alcohol consumption during pregnancy on fetal growth and morphogenesis. J Pediatr 1978;92:457-60. 9. Harrigan JA. Children of alcoholics. Am Fam Physician 1987;35(1):139-44. 10. Tarr JE, Macklin M. Cocaine. Pediatr Clin North Am 1987;34:319-31. 11. Jekel JF, Allen DF. Trends in drug abuse in the mid-1980s. Yale J Biol Med 1987;60:45-52. 12. Gold MS, Washton AM, Dackis CA. Cocaine abuse: neurochemistry, phenomenology, and treatment. Natl Inst Drug Abuse Res Monogr Ser 1985;61:130-50. 13. Chasnoff IJ, Burns KA, Burns WJ. Cocaine use in pregnancy: perinatal morbidity and mortality. Neurotoxicol Teratol 1987;9:291-3. 14. Greenstein RA, Resnick RB, Resnick E. Methadone and naltrexone in the treatment of heroin dependence. Psychiatr Clin North Am 1984; 7:671-9. 15. Hutchings DE. Methadone and heroin during pregnancy: a review of behavioral effects in human and animal offspring. Neurobehav Toxicol Teratol 1982;4:429-34. 16. Booth W. AIDS and drug abuse: no quick fix [News]. Science 1988;239(4841 Pt 1):717-9. 17. Jones RT. Marijuana: health and treatment issues. Psychiatr Clin North Am 1984;7:703-12. 18. Schwartz RH. Marijuana: an overview. Pediatr Clin North Am 1987;34:305-17. 19. Annual summary of births, marriages, divorces, and deaths, United States, 1987. Hyattsville, Md.: Public Health Service, 1988; DHHS publication no. (PHS)88-1120, (Monthly vital statistics report; vol. 36, no. 13). 20. Drinking and driving and binge drinking in selected states, 1982 and 1985: the Behavioral Risk Factor Surveys [Published errata appear in MMWR 1987;36:59 and 1987;36:11]. MMWR 1987;35:788-91. 21. ADAMHA update: facts from the 1987 National High School Senior Survey. Rockville, Md.: Alcohol, Drug Abuse, and Mental Health Administration, 1988. 22. Wheeler K, Malmquist J. Treatment approaches in adolescent chemical dependency. Pediatr Clin North Am 1987;34:437-47. 23. Glaze LW, Coggan PG. Efficacy of an alcoholism self-report questionnaire in a residency clinic. J Fam Pract 1987;25:60-4. 24. Sobell LC, Sobell MB. Outpatient alcoholics give valid self-reports. J Nerv Ment Dis 1975; 161:32-42. 25. Dean JC, Poremba GA. The alcoholic stigma and the disease concept. Int J Addict 1983;18: 739-51. 26. Cyr MG, Wartman SA. The effectiveness of
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