OBJECTIVE: To compare self-administered versions of three questionnaires for detecting heavy and problem drinking: the CAGE, the Alcohol Use Disorders Identification Test (AUDIT), and an augmented version of the CAGE.
DESIGN: Cross-sectional surveys.
SETTING: Three Department of Veterans Affairs general medical clinics.
PATIENTS: Random sample of consenting male outpatients who consumed at least 5 drinks over the past year (“drinkers”). Heavy drinkers were oversampled.
MEASUREMENTS: An augmented version of the CAGE was included in a questionnaire mailed to all patients. The AUDIT was subsequently mailed to “drinkers.” Comparison standards, based on the tri-level World Health Organization alcohol consumption interview and the Diagnostic Interview Schedule, included heavy drinking (>14 drinks per week typically or ≥5 drinks per day at least monthly) and active DSM-IIIR alcohol abuse or dependence (positive diagnosis and at least one alcohol-related symptom in the past year). Areas under receiver operating characteristic curves (AUROCs) were used to compare screening questionnaires.
MAIN RESULTS: Of 393 eligible patients, 261 (66%) returned the AUDIT and completed interviews. For detection of active alcohol abuse or dependence, the CAGE augmented with three more questions (AUROC 0.871) performed better than either the CAGE alone or AUDIT (AUROCs 0.820 and 0.777, respectively). For identification of heavy-drinking patients, however, the AUDIT performed best (AUROC 0.870). To identify both heavy drinking and active alcohol abuse or dependence, the augmented CAGE and AUDIT both performed well, but the AUDIT was superior (AUROC 0.861).
CONCLUSIONS: For identification of patients with heavy drinking or active alcohol abuse or dependence, the self-administered AUDIT was superior to the CAGE in this population.
Buchsbaum DG, Buchanan RG, Centor RM, Schnoll SH, Lawton MJ. Screening for alcohol abuse using CAGE scores and likelihood ratios. Ann Intern Med. 1991;115:774–7.PubMedGoogle Scholar
Connors GJ. Screening for alcohol problems. In: Allen JP, Columbus M, eds. Assessing Alcohol Problems: A Guide for Clinicians and Researchers. Bethesda, Md: National Institutes of Health; 1995;17–29. NIH publication 95–3745.Google Scholar
Barry KL, Fleming MF. Computerized administration of alcoholism screening tests in a primary care setting. J Am Board Fam Pract. 1990;3:93–8.PubMedGoogle Scholar
Buchsbaum DG, Buchanan RG, Welsh J, Centor RM, Schnoll SH. Screening for drinking disorders in the elderly using the CAGE questionnaire. J Am Geriatr Soc. 1992;40:662–5.PubMedGoogle Scholar
Chan AK, Pristach EA, Welte JW. Detection by the CAGE of alcoholism or heavy drinking in primary care outpatients and the general population. J Subst Abuse. 1994;6(2):123–35.PubMedCrossRefGoogle Scholar
Chan AK, Pristach EA, Welte JW, Russell M. Use of the TWEAK test in screening for alcoholism/heavy drinking in three populations. Alcohol Clin Exp Res. 1993;17(6):1188–92.PubMedGoogle Scholar
Cherpitel CJ. Analysis of cut points for screening instruments for alcohol problems in the emergency room. J Stud Alcohol. 1995;56:695–700.PubMedGoogle Scholar
Cherpitel CJ, Clark WB. Ethnic differences in performance of screening instruments for identifying harmful drinking and alcohol dependence in the emergency room. Alcohol Clin Exp Res. 1995;19(3):628–34.PubMedCrossRefGoogle Scholar
Jones TV, Lindsey BA, Yount P, Soltys R, Farani-Enayat B. Alcoholism screening questionnaires: are they valid in elderly medical outpatients? J Gen Intern Med. 1993;8:674–8.PubMedCrossRefGoogle Scholar
Joseph CL, Ganzini L, Atkinson RM. Screening for alcohol use disorders in the nursing home. J Am Geriatr Soc. 1995;43:368–73.PubMedGoogle Scholar
Liskow B, Campbell J, Nickel EJ, Powell BJ. Validity of the CAGE questionnaire in screening for alcohol dependence in a walk-in (triage) clinic. J Stud Alcohol. 1995;56:277–81.PubMedGoogle Scholar
Magruder-Habib K, Stevens HA, Alling WC. Relative performance of the MAST, VAST, and CAGE versus DSM-III-R criteria for alcohol dependence. J Clin Epidemiol. 1993;46(5):435–41.PubMedCrossRefGoogle Scholar
Morton J, Jones T, Manganaro M. Performance of alcoholism screening questionnaires in elderly veterans. Am J Med. 1996;101:153–9.PubMedCrossRefGoogle Scholar
Bradley, KA, Donovan DM, Larson EB. How much is too much? Advising patients about safe levels of alcohol consumption. Arch Intern Med. 1993;153:2734–40.PubMedCrossRefGoogle Scholar
Sanchez-Craig M, Wilkinson A, Davila R. Empirically based guidelines for moderate drinking: one year results from three studies with problem drinkers. Am J Public Health. 1995;85(6):823–8.PubMedGoogle Scholar
Dawson DA, Grant BF, Harford TC. Variation in the association of alcohol consumption with five DSM-IV alcohol problem domains. Alcohol Clin Exp Res. 1995;19(1):66–74.PubMedGoogle Scholar
Wechsler H, Davenport A, Dowdall G, Moeykens B, Castillo S. Health and behavioral consequences of binge drinking in college. JAMA. 1994;272:1672–7.PubMedCrossRefGoogle Scholar
Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. JAMA. 1997;277(13):1039–45.PubMedCrossRefGoogle Scholar
Adams WL, Barry KL, Fleming MF. Screening for problem drinking in older primary care patients. JAMA. 1996;276:1964–7.PubMedCrossRefGoogle Scholar
Saunders JB, Aasland OG, Babor TF, De La Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption, II. Addiction. 1993;88:791–804.PubMedCrossRefGoogle Scholar
Fleming MF, Barry KL. A three-sample test of a masked alcohol screening questionnaire. Alcohol Alcohol. 1991;26(1):81–91.PubMedGoogle Scholar
Wallace P, Haines A. Use of a questionnaire in general practice to increase the recognition of patients with excessive alcohol consumption. BMJ. 1985;290:1949–52.PubMedCrossRefGoogle Scholar
Babor TF, Grant M. From clinical research to secondary prevention—international collaboration in the development of of the Alcohol Use Disorders Identification Test (AUDIT). Alcohol Health Res World. 1989;13(4):371–4.Google Scholar
Saunders JB, Aasland OG, Amundsen A, Grant M. Alcohol consumption and related problems among primary health care patients: WHO collaborative project on early detection of harmful alcohol consumption, I. Addiction. 1993;88:349–62.PubMedCrossRefGoogle Scholar
Saunders JB, Aasland OG. WHO Collaborative Project on Identification and Treatment of Persons with Harmful Alcohol Consumption: Report on Phase I, Development of a Screening Instrument. Geneva, Switzerland: World Health Organization, Divison of Mental Health; 1987.Google Scholar
Miller WR, Heather N, Hall W. Calculating standard drink units: international comparisons. Br J Addict. 1991;86:43–7.PubMedCrossRefGoogle Scholar
Robins LN, Helzer JE, Croughan J, Ratcliff KS. National Institute of Mental Health Diagnostic Interview Schedule. Arch Gen Psychiatry. 1981;38:381–9.PubMedGoogle Scholar
Fleming MF, Barry KL, MacDonald R. The Alcohol Use Disorders Identification Test (AUDIT) in a college sample. Int J Addict. 1991;26(11):1173–85.PubMedGoogle Scholar
Schmidt A, Barry K, Fleming MF. Detection of problem drinkers: the Alcohol Use Disorders Identification Test. South Med J. 1995;88(1):52–9.PubMedGoogle Scholar
Ingelfinger JA, Mosteller F, Thibodeau LA, Ware JH. Biostatistics in Clinical Medicine. 3rd ed. New York, NY: McGraw-Hill; 1994.Google Scholar
Zweig MH, Campbell G. ROC plots: a fundamental evaluation tool in clinical medicine. Clin Chem. 1993;39:561–77.PubMedGoogle Scholar
Centor RM, Schwartz JS. An evaluation of methods for estimating the area under the ROC curve. Med Decis Making. 1985;5:149–56.PubMedCrossRefGoogle Scholar
Hanley JA, McNeil BJ. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology. 1983;148:839–43.PubMedGoogle Scholar
Cutler SF, Wallace PG, Haines AP. Assessing alcohol consumption in general practice patients—a comparison between questionnaire and interview. Alcohol Alcohol. 1988;23(6):441–50.PubMedGoogle Scholar
Isaacson HJ, Butler R, Zacharek M, Tzelepis A. Screening with the Alcohol Use Disorders Identification Test (AUDIT) in an inner city population. J Gen Intern Med. 1994;9:550–3.PubMedCrossRefGoogle Scholar
Volk RJ, Steinbauer JR, Cantor SB, Holzer CE III. The Alcohol Use Disorders Identification Test (AUDIT) as a screen for at-risk patients of different racial/ethnic backgrounds. Addiction. 1997;92(2):197–206.PubMedCrossRefGoogle Scholar
Schuckit MA, Hesselbrock V, Tipp J, Anthenelli R, Bucholz K, Radziminski S. A comparison of DSM-III-R, DSM-IV and ICD-10 substance use disorders diagnoses in 1922 men and women subjects in the COGA study. Collaborative Study on the Genetics of Alcoholism. Addiction. 1994;89(12):1629–38.PubMedCrossRefGoogle Scholar
Barry KL, Fleming MF. The Alcohol Use Disorders Identification Test (AUDIT) and the SMAST-13: predictive validity in a rural primary care sample. Alcohol. 1993;28(1):33–42.Google Scholar
Fertig JB, Allen JP, Cross GM. CAGE as a predictor of hazardous alcohol consumption in U.S. Army personnel. Alcohol Clin Exp Res. 1993;17(6):1184–7.PubMedGoogle Scholar
Richmond R, Heather N, Wodak A, Kehoe L, Webster I. Controlled evaluation of a general practice based brief intervention for excessive drinking. Addiction. 1995;90:119–32.PubMedCrossRefGoogle Scholar
CDC. Health risk factor surveys of commercial plan- and Medicaid-enrolled members of health-maintenance organizations-Michigan 1995. MMWR. 1997;46(39):923–6.Google Scholar
Buchsbaum DG, Buchanan RG, Poses RM, Schnoll SH, Lawton MJ. Physician detection of drinking problems in patients attending a general medicine practice. J Gen Intern Med. 1992;7(5):517–21.PubMedCrossRefGoogle Scholar
Buchsbaum DG, Buchanan RG, Lawton MJ, Elswick RKJ, Schnoll SH. A program of screening and prompting improves short-term physician counseling of dependent and nondependent harmful drinkers. Arch Intern Med. 1993;153(13):1573–7.PubMedCrossRefGoogle Scholar
Goldberg HI, Mullen M, Ries RK, Psaty BM, Ruch BP. Alcohol counseling in a general medicine clinic: a randomized controlled trial to improve referral and show rates. Med Care. 1991;29(7 suppl):JS49–56.PubMedGoogle Scholar