Alcohol screening in young persons attending a sexually transmitted disease clinic

Comparison of AUDIT, CRAFFT, and CAGE instruments

Abstract

OBJECTIVE: To compare the ability of 3 brief alcohol screens (Alcohol Use Disorders Identification Test [AUDIT], CRAFFT, and CAGE) to identify adolescents and young adults with a current alcohol use disorder (AUD) and to determine whether there are gender-based or race-based differences in screening performance.

DESIGN, PARTICIPANTS, AND SETTING: Cross-sectional study of 358 young persons (55% males; 49% blacks; age range, 15–24 years; mean age, 20.6 years) who were attending an urban clinic for sexually transmitted diseases and reported alcohol use during the past year.

MEASUREMENTS: Receiver operating characteristic (ROC) curve analysis was used to determine the ability of the 3 screens to discriminate between participants with and without AUDs detected in the Structured Clinical Interview for DSM-IV (SCID).

RESULTS: One third (33%) of participants met Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for a current AUD (24% with alcohol abuse and 9% with alcohol dependence). The AUDIT performed best at a cut score of 9 (sensitivity, 0.76; specificity, 0.79), CRAFFT at a cut score of 2 (sensitivity, 0.94; specificity, 0.33), and CAGE at a cut score of 1 (sensitivity, 0.69; specificity, 0.63). The AUDIT had the best overall performance (area under the curve [AUC], 0.84), followed closely by CRAFFT (AUC, 0.79) and then CAGE (AUC, 0.70). Performance of screens did not differ by gender. The AUDIT performed slightly better in whites than blacks, but no race-based differences were observed for the CAGE or CRAFFT.

CONCLUSIONS: Clinicians should use the AUDIT or CRAFFT, rather than the CAGE, to screen young persons for AUDs. The AUDIT performs best, but its length may limit its utility in this setting. The CRAFFT is a suitable alternative, with excellent sensitivity and no gender-based or race-based differences.

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References

  1. 1.

    Committee on Developing a Strategy to Reduce and Prevent Underage Drinking, Bonnie RJ, O'Connell ME, eds. Reducing Underage Drinking: A Collective Responsibility. Washington, DC: National Academies Press, 2003.

    Google Scholar 

  2. 2.

    U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. Baltimore, MD: Williams & Wilkins; 1996.

    Google Scholar 

  3. 3.

    O’Connor PG, Schottenfeld RS. Patients with alcohol problems. N Engl J Med. 1998;338:592–602.

    PubMed  Article  CAS  Google Scholar 

  4. 4.

    Kelly TM, Donovan JE, Cornelius JR, Bukstein OG, Delbridge TR, Clark DB. Psychiatric disorders among older adolescents treated in emergency departments on weekends: a comparison with a matched community sample. J Stud Alcohol. 2003;64:616–22.

    PubMed  Google Scholar 

  5. 5.

    Deitz D, Rohde M, Bertolucci M, Dufour M. Prevalence of screening for alcohol use by physicians during routine physical examination. Alcohol Health Res World. 1994;18:162–8.

    Google Scholar 

  6. 6.

    Conigliaro J, Gordon AJ, McGinnis KA, Rabeneck L, Justice AC. How harmful is hazardous alcohol use and abuse in HIV infection: do health care providers know who is at risk? J Acquir Immune Defic Syndr. 2003;33:521–5.

    PubMed  CAS  Google Scholar 

  7. 7.

    Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252:1905–7.

    PubMed  Article  CAS  Google Scholar 

  8. 8.

    Babor T, Ramon de la Fuente J, Saunders J, Grant M. The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care. WHO Publication No. 89.4. Geneva, Switzerland: World Health Organization; 1989.

    Google Scholar 

  9. 9.

    Knight JR, Shrier LA, Bravender TD, Farrell M, Vander Bilt J, Shaffer HJ. A new brief screen for adolescent substance abuse. Arch Pediatr Adolesc Med. 1999;153:591–6.

    PubMed  CAS  Google Scholar 

  10. 10.

    Chung T, Colby SM, Barnett NP, Rohsenow DJ, Spirito A, Monti PM. Screening adolescents for problem drinking: performance of brief screens against DSM-IV alcohol diagnoses. J Stud Alcohol. 2000;61:579–87.

    PubMed  CAS  Google Scholar 

  11. 11.

    Clements R. A critical evaluation of several alcohol screening instruments using the CIDI-SAM as a criterion measure. Alcohol Clin Exp Res. 1998;22:985–93.

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Knight JR, Sherritt L, Harris SK, Gates EC, Chang G. Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res. 2003;27:67–73.

    PubMed  Google Scholar 

  13. 13.

    O’Hare T, Tran TV. Predicting problem drinking in college students: gender differences and the CAGE questionnaire. Addict Behav. 1997;22:13–21.

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Cherpitel CJ. Screening for alcohol problems in the U.S. general population: a comparison of the CAGE and TWEAK by gender, ethnicity, and services utilization. J Stud Alcohol. 1999;60:705–11.

    PubMed  CAS  Google Scholar 

  15. 15.

    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;19:628–34.

    PubMed  Article  CAS  Google Scholar 

  16. 16.

    Bradley KA, Boyd-Wickizer J, Powell SH, Burman ML. Alcohol screening questionnaires in women: a critical review. JAMA. 1998;280:166–71.

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    Aertgeerts B, Buntinx F, Fevery J, Ansoms S. Is there a difference between CAGE interviews and written CAGE questionnaires? Alcohol Clin Exp Res. 2000;24:733–6.

    PubMed  Article  CAS  Google Scholar 

  18. 18.

    Maisto SA, Conigliaro J, McNeil M, Kraemer K, Kelley ME. An empirical investigation of the factor structure of the AUDIT. Psychol Assess. 2000;12:346–53.

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Chung T, Colby SM, Barnett NP, Monti PM. Alcohol use disorders identification test: factor structure in an adolescent emergency department sample. Alcohol Clin Exp Res. 2002;26:223–31.

    PubMed  Google Scholar 

  20. 20.

    Kelly TM, Donovan JE. Confirmatory factor analyses of the alcohol use disorders identification test (AUDIT) among adolescents treated in emergency departments. J Stud Alcohol. 2001;62:838–42.

    PubMed  CAS  Google Scholar 

  21. 21.

    Martin CS, Kaczynski NA, Maisto SA, Bukstein OM, Moss HB. Patterns of DSM-IV alcohol abuse and dependence symptoms in adolescent drinkers. J Stud Alcohol. 1995;56:672–80.

    PubMed  CAS  Google Scholar 

  22. 22.

    Martin CS, Kaczynski NA, Maisto SA, Tarter RE. Polydrug use in adolescent drinkers with and without DSM-IV alcohol abuse and dependence. Alcohol Clin Exp Res. 1996;20:1099–108.

    PubMed  Article  CAS  Google Scholar 

  23. 23.

    Martin C, Pollock N, Bukstein O, Lynch K. Inter-rater reliability of the SCID alcohol and substance use disorders section among adolescents. Drug Alcohol Depend. 2000;59:173–6.

    PubMed  Article  CAS  Google Scholar 

  24. 24.

    DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a non parametric approach. Biometrics. 1998;44:837–45.

    Article  Google Scholar 

  25. 25.

    Reinert DF, Allen JP. The Alcohol Use Disorders Identification Test (AUDIT): a review of recent research. Alcohol Clin Exp Res. 2002;26:272–9.

    PubMed  Google Scholar 

  26. 26.

    Steinbauer JR, Cantor SB, Holzer CE III, Volk RJ. Ethnic and sex bias in primary care screening tests for alcohol use disorders. Ann Intern Med. 1998;129:353–62.

    PubMed  CAS  Google Scholar 

  27. 27.

    Fleming MF, Barry KL, MacDonald R. The alcohol use disorders identification test (AUDIT) in a college sample. Int J Addict. 1991;26:1173–85.

    PubMed  CAS  Google Scholar 

  28. 28.

    Kraemer HC. Evaluating Medical Tests: Objective and Quantitative Guidelines. Newbury Park, CA: Sage Publications; 2000.

    Google Scholar 

  29. 29.

    Cherpitel CJ. Differences in performance of screening instruments for problem drinking among blacks, whites and Hispanics in an emergency room population. J Stud Alcohol. 1998;59:420–6.

    PubMed  CAS  Google Scholar 

  30. 30.

    Clark DB, Winters KC. Measuring risks and outcomes in substance use disorders prevention research. J Consult Clin Psychol. 2002;70:1207–23.

    PubMed  Article  Google Scholar 

  31. 31.

    Monti P, Barnett N, O'Leary T, Colby S. Motivational enhancement for alcohol-involved adolescents. In: Monti P, Colby S, O'Leary T, eds. Adolescents, Alcohol and Substance Abuse. New York, NY: Guilford Press; 2001:145–82.

    Google Scholar 

  32. 32.

    Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. JAMA. 1997;277:1039–45.

    PubMed  Article  CAS  Google Scholar 

  33. 33.

    Samet JH, Rollnick S, Barnes H. Beyond CAGE. A brief clinical approach after detection of substance abuse. Arch Intern Med. 1996;156:2287–93.

    PubMed  Article  CAS  Google Scholar 

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Correspondence to Dr. Robert L. Cook MD, MPH.

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None of the authors has any conflict of interest relevant to this manuscript or the data.

This research was presented in part at the June 22–26, 2003 annual meeting of the Research Society on Alcoholism, Ft. Lauderdale, FL.

See editorial by O'Connor, p. 96–97.

This work was supported by federal grants K23AA00303-01, K02 AA000291, K-08-AA00280, and K01 AA00324 from the National Institute of Alcohol Abuse and Alcoholism.

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Cook, R.L., Chung, T., Kelly, T.M. et al. Alcohol screening in young persons attending a sexually transmitted disease clinic. J GEN INTERN MED 20, 1–6 (2005). https://doi.org/10.1111/j.1525-1497.2005.40052.x

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Key Words

  • alcoholism
  • alcohol drinking
  • screening
  • adolescents