Screening Hospitalized Injured Drivers and Other Trauma Victims for Alcoholism Using Two Questions

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1 Screening Hospitalized Injured Drivers and Other Trauma Victims for Alcoholism Using Two Questions C arl A. S o d e r str o m, M.D.,1 P a tricia C. D isc h in g e r, P h.d.,2 G ord on S. S m ith, M.D.3 S h iu M. H o, M.A.,2 T im o th y J. K ern s, M.S.2 R A dam s C ow ley S hock T raum a C enter, U niversity o f M aryland M edical C enter,22 South G reene Street; B altim ore, M D 21201; U.S.A. D epartm ent o f Surgery/Traum atology, R A C Shock Traum a Center; ^ h e N ational Study C enter for T raum a and E M S, U niversity o f M aryland at Baltim ore; 3T he C enter for Injury R esearch and Policy; T he Johns H opkins U niversity (B altim ore). IN T R O D U C T IO N The association o f alcohol use and injury from various m echanism s is well established (Lundberg, 1984; D H H S, 1994). R ecently, a num ber o f reports have docum ented that the rates o f alcohol abuse and dependence (alcoholism ) am ong injured patients treated in traum a centers and em ergency departm ents range from 13% to 44% (Rivara et al, 1993; C herpitel, 1995; Maio et al, 1997; Soderstrom et al, 1997). V ariations in results are m ost likely dependent on the traum a population under study (all victim s vs vehicular crash victims; traum a center patients vs em ergency departm ent patients), type o f instrum ent (screening test vs in-depth interview ), and diagnostic criteria (D SM, ICD, other) (DHHS). T o institute treatm ent for an underlying alcohol dependence (alcoholism ) o r abuse problem, it is necessary to identify that problem. In a busy traum a center, m ost clinicians caring for injured patients have little expertise in substance use disorders. T hey focus their efforts on diagnosing and treating life-threatening injuries. Therefore, to enable those clinicians to screen fo r patients at risk o f an alcohol problem, an instrum ent consisting o f as few questions as possible w ould be ideal. Screen-positive patients w ould then be referred to substance abuse clinicians for form al evaluations and institution of therapy as necessary. In 1982, a m ultinational task force o f alcohol researchers developed the A lcohol U se D isorders Identification T est (A U D IT) (Babor et al, 1992; Saunders et al, 1993). The 10-item A U D IT is designed to identify individuals at risk o f alcohol problem s including alcohol dependence. The first three questions concern quantity and frequency o f drinking, the rem aining questions alcohol dependence and consequences o f drinking. E ach response is scored 0 to 4. A total score >8 suggests "hazardous or harm ful" alcohol consum ption

2 The National Institute on Alcohol A buse and A lcoholism (NIAAA) recently published guidelines to help busy prim ary care physicians identify patients w ith alcohol problem s (N IA A A, 1995). A ccording to those guidelines, m oderate drinking for a m an consists o f no m ore than tw o drinks per day. Further, possible problem atic drinking is defined as drinking m ore than 14 drinks per w eek or consum ing m ore than 4 drinks p er occasion. H ence, a man drinking 4 drinks per day w ho w ould be under the drinks-per-occasion limit w ould exceed 14 drinks in 4 days o f drinking. F or a w om an, not exceeding one drink p er day is considered m oderate drinking. Possible problem atic drinking is defined as m ore than seven drinks per w eek or m ore than three drinks per occasion. H ence, even if a w om en drank no m ore than three drinks per day, she w ould exceed the w eekly lim it in 3 days o f drinking. The first tw o A U D IT questions ask about drinking patterns in a m anner that w ould allow one to identify patients at risk o f problem drinking consistent w ith N IAAA guidelines. Q uestion #1 asks, "H ow often do you have a drink containing alcohol?" The highest level provided in the answ ers is "4 or m ore tim es p er week" (preceded by "2 o r 3 tim es per w eek"). The second A U D IT question asks, "H ow m any drinks containing alcohol do you have on a typical day w hen you are drinking?" The third response o f five is "5 or 6" (preceded by a response o f "3 or 4"). H ence, in the case o f both m en and w om en, an A U D IT response to question #1 indicating drinking 4 or m ore days per w eek or a response to question #2 indicating the drinking o f 5 or m ore drinks per occasion w ould be roughly com patible with drinking patterns defined in NIAAA guidelines suggesting problem atic drinking. (Due to response break points in the A U D IT questions, approxim ate NIAAA guidelines can be assessed using the AUDIT questions.) W e assessed the utility o f using specific responses to A U D IT questions #1 and #2 to screen traum a center patients for current alcohol dependence. S T U D Y D E S IG N Clinical Site and Study Population. The R A dam s C ow ley Shock T raum a C enter is a busy Level I regional serving adult traum a victim s injured in both rural and urban settings. Period o f Study and Entry Criteria. From M ay 1994 through April 1996, all patients m eeting the follow ing criteria w ere eligible for study: 1) age >18 years, 2) adm ission direct from the scene o f injury, 3) length o f stay >2 days, and 4) intact cognition. D iagnostic Instrum ents/h IG H and LO W Threshold R esponses to A U D IT #1 and #2. Patients w ere assessed by clinicians specially trained in adm inistration o f the psychoactive substance use disorders (PSU D ) section o f the Structured Clinical Interview for D S M -III-R (SC ID ). The SCID is a widely accepted instrum ent (DHHS) that uses D SM -III-R criteria to diagnose alcohol

3 abuse and dependence. T he SCID allow s alcohol dependence diagnoses to be classified into current (w ithin the past 6 m onths) and lifetim e (past, but not current). P rior to adm inistration o f the SCID, subjects w ere given four screening questionnaires for alcohol/drug problem s, including the com plete AUDIT. A s noted above, som e responses to the A U D IT #1 and #2 questions approxim ate NIAAA guidelines for alcohol problem s. W e chose the follow ing responses as H IG H and LOW thresholds: #1 D rinking p er w eek - H IG H threshold = > 4 tim es/w eek, L O W threshold = 2 o r 3 tim es/w eek; # 2 D rinks p e r occasion - H IG H threshold = >5 drinks/occasion, LO W threshold = 3 or 4 drinks/occasion. A nalysis o f R esults. T he SCID results provided alcohol diagnoses. T he efficacy o f H IG H and LOW threshold A U D IT responses #1 and #2 to screen for current alcoholism am ong injured drivers and other traum a victim s w as determ ined using calculation o f sensitivity and specificity. E fficacy w as for single responses and com bination o f responses. R E S U L T S A total o f 979 patients provided com plete interview s. T he profile o f interview ed subjects was as follow s: sex % m en and 29.6% w om en; m echanism s o f injury (52.1% ) vehicular crash victim s (347 car/truck occupants, 101 pedestrians, 62 m otorcyclists); 171 (17.5% ) other non-violence victim s (75% fall victim s); and 298 (30.4% ) victim s o f violence (61.7% shooting victim s). B ased on m echanism o f injury, the largest group consisted o f 338 (34.5% ) injured drivers (291 car/truck, 47 m otorcycle). R elative to SCID diagnoses, 561 patients (57.3% ) had no alcohol diagnosis; 354 (36.2% ) had a diagnosis o f alcohol dependence, o f w hom alm ost tw o-thirds (65.5% ) had current dependence; and 64 (6.5% ) had a diagnosis o f abuse. ("A buse" is a residual diagnosis for individuals w ho experience negative consequences from their drinking, but w ho do not m eet the criteria for dependence [Soderstrom et al, 1992].) The com plete A U D IT test had an overall sensitivity o f.94 (range, ) and specificity o f.84 (range, ) in detecting current alcohol dependence am ong the groups o f patients injured as the result o f different m echanism s. In Table 1, the sensitivity and specificity o f H IG H and L O W threshold responses alone and in com bination in detecting current alcoholism in the various groups o f patients are presented

4 T ab le 1 : E ffic a c y o f A U D IT Q u e stio n s in D ia g n o sin g C u rren t A lc o h o l D e p en d en ce (T op fig u r e, se n sitiv ity ; B o tto m fig u r e, sp e c ific ity ) O ther Other Overall Drivers Vehicular N on-v iol Violence fn=9791 n=3381 fn=1721 fn = 1 7 n fn=2981 H IG H Threshold A UDIT # drinks >4/w eek A UDIT # >5 drinks/day A UDIT #1 & # Both positive A UDIT #1 & # Either positive LOW Threshold A UDIT # drinks >2-3/w eek AUDIT # >3 drinks/day AU DIT #1 & # Both positive AUDIT #1 & # Either positive A m ong drivers, the H IG H threshold responses to A U D IT #1 and #2 had sensitivities o f.47 and.57, w ith specificities o f.98 and.91, respectively. T hese results w ere com parable to those obtained fo r those questions am ong patients injured as the result o f other m echanism s. By low ering the threshold fo r each o f the questions am ong injured drivers, the sensitivity o f A U D IT #1 and #2 increased.25 and.26, respectively, w hile the specificities rem ained relatively H IG H (.87 f o r # l,.70 for #2). Sim ilarly, by low ering the threshold response for each question for other traum a victim s, the sensitivity for detecting current alcoholism increased.19 to.27 for #1, and.19 to.34 for #2, w hile the specificities rem ained relatively H IG H (range, for #1, and for #2). O verall, sensitivities o f.90 or greater for detecting

5 current alcoholism w ere noted w ith a low -threshold positive response to either #1 o r #2, with specificities ranging from.62 to.64. D I S C U S S I O N (In this discussion, the num erical param eters used to define "fair" [.40 to.65], "good" [.70 to.85], and "excellent" [>.85] results are based on the judgm ent o f the researchers.) The results suggest that the H IG H threshold responses to the tw o A U D IT questions individually result in fair sensitivity rates and good to excellent specificity rates in detecting current alcoholism am ong injured drivers as well as other victim s o f traum a. T he application o f LOW er threshold responses generally increased sensitivity o f the individual questions in detecting alcoholism to the good to excellent range while m aintaining good specificity levels in the sam e groups o f patients. Further, w hen H IG H o r L O W threshold responses are applied for either o f the tw o questions used together, good to excellent sensitivity and specificity rates are obtained for all traum a victim s. A nda and colleagues (1988) noted that, independent o f a num ber o f factors, individuals w ho consum ed >5 and >9 drinks per occasion had 1.9 and 3.3 tim es higher probabilities, respectively, o f dying from injury com pared w ith people w ho consum ed less alcohol. U nfortunately, there is a dearth o f inform ation concerning the drinking patterns o f adults w ho survive injury and consum ption patterns am ong alcoholic and non-alcoholic traum a patients. In this study, w e found that com bined good to excellent sensitivities and specificities in the detection o f current alcoholism are obtained by using threshold responses considerably below N IA A A screening guidelines. T he results suggest that alcohol-dependent traum a center patients m ay be earlier in the course o f their disease than alcoholics identified in other clinical settings. This is not surprising, given that alcoholic traum a center patients are generally younger than those encountered in those other settings (R ivara et al, 1993; C herpitel, 1995; M aio et al, 1997; Soderstrom et al, 1997). F urther, our results are not surprising w hen exam ined in light o f one o f the few reports assessing drinking patterns am ong non-fatal traum a victim s. In that report, Cherpitel and colleagues (1995) docum ented that the risk o f non-fatal injuries in m en and w om en w as increased even at "relatively low levels," i.e., 1 drink p er day, and peaked at 2 to 3 drinks/day for m en and 3 to 4 drinks/day for w om en. T his study suggests that using A U D IT questions #1 and #2 w ith LO W drinking thresholds will provide traum a clinicians w ill a rapid m ethod to identify traum a center patients at risk o f alcohol dependence. Additional studies are needed to define drinking patterns am ong alcoholic and nonalcoholic individuals in that unique patient population

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