Identifying and characterizing alcohol at-risk individuals in a university emergency department...

Identifying and characterizing alcohol at-

risk individuals in a

university emergency department utilizing AUDIT-

C within a short general health screen:

A pilot study

Presenter: Arshadul Haque MBBS, MPH

J Helmkamp PhD, S Swisher McClure BS, J Williams MD, P Ehrlich MD, W Manley RN

Research Group

Research Funded by grant from CDC/NCIPC

• Alcohol use is pervasive in our society. About 50% of all Americans ages 12 and olderare current drinkers which translates to 120 million people.1

• A wide range of physical, social and psychological problems are associated with excessive drinking

• Annual economic cost to the nation is approximately $148 billion2

Introduction1

Introduction2

• Why early detection and treatment?

• Where can early detection occur?

• How is early detection facilitated?

• How can detection improve?

Difficulties and Problems

• What are the barriers in early detection?

• Are providers increasing their scope of screening in their regular practice?

• “Missed opportunities” and various “teachable moments”.3

Additional Problem

• There is a growing size of the population who are accessing the ED as the only source of care and do not have primary care physicians4

Alcohol Screening Instruments

• To name a few: TWEAK, CAGE, AUDIT, MAST, etc.

• Alcohol Use Disorders Identification Test (AUDIT), a 10-item questionnaire

• However, the AUDIT still remains to be routinely incorporated in routine health screening

• Likely limitation is the 10 items itself and the required training for its interpretation

Current Research

• AUDIT-C has been found to be equally specific compared to the full instrument5

• However, three screening questions related to alcohol use will not cover the full scope of detecting alcohol problems

Research study objectives

• To explore the feasibility of inclusion of a short alcohol screening tool within a general health screen

• To identify patients with alcohol problems with AUDIT-C. Subsequently, characterize the full range of alcohol problems; intake, dependence and harm conditions

• Finally, to study the associations of screened positive individuals with other items of a general health screen

Methods• Study Period : August 2001 to July 2002

• Patients coming to the ED were approached to participate in the study

• Eligibility was determined based on age criteria (18-39 years)

• Consent to participate in the study and to receive information was

obtained

• A short general health screen was provided with AUDIT-C questions

Methods

• Using AUDIT-C cut off score of 4, patients were further evaluated with the full AUDIT questionnaire

• Other co-morbidity information was also collected

• Patients were provided with feedback and a brief intervention based on the methods described by Miller and Rollnick

AUDIT-C; Intake section

1. In the past year, how many drinks containing alcohol do you have on a typical day, when you are drinking?

1 or 2 3 or 4 5 or 6 7 or 9 10 or more 0 1 2 3 4

 2. How often do you drink that amount?

Never <Monthly Monthly Weekly Daily/almost daily 0 1 2 3 4

3. How often in the past year you had 5 (male)/4 (female) or more drinks on one occasion?

Never <Monthly Monthly Weekly Daily/almost daily 0 1 2 3 4

AUDIT- Dependence section1. How often during the past year have you found that you were not able to

stop drinking once you had started?Never <Monthly Monthly Weekly Daily/almost daily

0 1 2 3 42. How often during the past year have you needed a first drink in the

morning to get yourself going after a heavy drinking session?

Never <Monthly Monthly Weekly Daily/almost daily 0 1 2 3 4 3. How often during the past year have you had a feeling of guilt or

remorse after drinking?Never <Monthly Monthly Weekly Daily/almost daily

0 1 2 3 4 4. How often during the past year have you been unable to remember what

happened the night before because you had been drinking?Never <Monthly Monthly Weekly Daily/almost daily

0 1 2 3 4 

AUDIT- Harm section1. How often during the past year have you not done what

was normally expected from you because of drinking? For example, have you ever missed work or class?Never <Monthly Monthly Weekly Daily/almost daily

0 1 2 3 42. Has your drinking contributed to an injury to yourself

or anyone else?Never Yes, but not in the last year Yes, during the last year

0 2 4 3. Has a relative, friend, doctor, or other health worker

been concerned about your drinking or suggested that you should cut down?Never Yes, but not in the last year Yes, during the last year

0 2 4 

Results of Patient process1

• 1991 patients were approached in the Emergency Department

• 96% (1910) met age and drinking eligible criteria

• 48% (925) patients consented to participate in the study

• Median time for the process to obtain consent was 3 minutes

Results of Patient process2

• 925 patients were administered the general health screen inclusive of AUDIT-C questions

• 26% (241) were found to be screen positive for alcohol problems (at AUDIT-C cut off score of 4)

• Median time to complete the screening process was 4 minutes

Patient Characteristics1

Consenting patient group (N=925) consisted of:

• Females 53% (484)

• Ages:

•18-20 yrs 21% (193)

•21-24 yrs 27% (246)

•25-39 yrs 52% (482)

• Race:

•White 95% (858)

•Black 4% (32)

•Asian/PI 1% (8)

Patient Characteristics2Other select characteristics of Consenting patient group:

• Students 30% (275)

• Completed Education level:

•Less than high school 16% (1145)

•High School/GED 35% (322)

•Some College 40% (368)

• Smokes Tobacco 51% (467)

• Not married 66% (607)

• Source of regular Medical Care:

•Private physician 41% (372)

•Emergency Department 27% (251)

Screen Positive and Screen Negative Patient Characteristics1

Screen-Pos Screen-Neg

•Gender (N=921)

Female 34% 59%

Male 66% 41%

• Ages:

18-20 yrs 31% 17%

21-39 yrs 69% 83%

• Student:

Currently a student 48% 23%

Not a current student 52% 77%

Screen Positive and Screen Negative Patient Characteristics2

Screen Pos Screen Neg

•Education Completed (N=917)

High School or Less 45% 53%

Some College or above 55% 47%

• Marital Status

Single 85% 59%

Married 15% 41%

•Tobacco Use (N=924)

Smoked 64% 46%

Did not Smoke 36% 54%

Screen Positive and Screen Negative Patient Characteristics3

Screen-Pos Screen-Neg

•Exercise (N=924)

Regular in activity 64% 55%

Do not Exercise 36% 45%

•Seatbelt Use

Always 55% 68%

Seldom/Never 45% 32%

• Source of Regular Health Care

ED 37% 24%

Other than ED 63% 76%

Drinking characteristics of Screen Positive Patients

Alcohol Intake* (N=241) • 3 or more drinks

per typical drinking day97%• 7 or more drinks

per typical drinking day53%

•Usually drank

•1 or fewer times per week50%

•2 to 3 times per week39%

•4 or more times per week11%

•Binged** 3 or more times in past two weeks

58%

Drinking characteristics of Screen Positive Patients

Dependence Symptoms Related to Drinking* (N=238)

• Not able to stop drinking once started§ 23%

• Needs drink in morning to get going§ 7%

• Feels guilt or remorse after drinking§ 27%

• Amnesia of events due to drinking§ 44%

Drinking characteristics of Screen Positive Patients

Harm Symptoms Related to Drinking* (N=238)

• Failed to fulfill normal expectations§

23%

• Injury to self or others§ 7%

• Relatives, friends, or health care providers express concern about drinking§

27%

Multiple Logistic Regression Analysis for AUDIT-C screen positive

patients OR 95%CI p-value

• Student (currently being a student) 3.4 1.9-6.3

<0.0001

• Not married/Single 3.1 1.7-5.8 0.0002

• Smokes Tobacco 2.8 1.6-4.7 0.0002

• Place for regular medical care (ED based) 2.1 1.2-3.6

0.0068

• Seatbelt use (Never/seldom uses seatbelts) 2.0 1.2-3.2 0.0092

Conclusions

• A short alcohol screening tool can be conveniently utilized within a general health screen

• Initial screen with this tool can facilitate further evaluation of alcohol problems

• Besides intake factors other risk factors are associated with alcohol problems

• Patients with certain profiles should arouse the curiosity of health care professionals to discuss alcohol related problems

References

1. Results from 2002 National Survey on Drug Use and Health (NSDUH) at www.samhsa.gov/oas/NHSDA/ 2K2NSDUH.Results/2h2results.htm

2. Harwood H, Fountain D et al. The economic costs of alcohol and drug abuse in the United Sates, 1992. NIH publication No. 98-4327, printed September 1998

3. Maio RF. Alcohol and injury in the emergency department: opportunities for intervention. Ann Emerg Med. 1995; 26: 221-223.

4. Cross LA.: Pressure on the emergency department:The expanding right to medical care. Ann Emerg Med. 1992; 21: 1266-1272.

5. Gordon A, Maisto S, et al. Three questions can detect hazardous drinkers. J of Fam Pract 2001;50(4):313-320