Single Screening Question May Accurately Identify Unhealthy Alcohol Use

Laurie Barclay, MD

March 17, 2009

January 11, 2010 — Editor's Note: In the fourth paragraph, the definition of a positive response to the unhealthy alcohol screen question was not accurate. The sentence has been corrected: "A positive response to this single-question screen was defined as 1 or more."

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March 17, 2009 (UPDATED January 11, 2010 — The single screening question recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) accurately identifies unhealthy alcohol use in a sample of primary care patients, supporting use of this brief screen in primary care, according to the results of a cross-sectional study reported in the March 12 Online First issue of the Journal of General Internal Medicine.

"Unhealthy alcohol use is prevalent but under-diagnosed in primary care settings," write Peter C. Smith, MD, MSc, from Boston University School of Medicine in Boston, Massachusetts, and colleagues. "Screening and brief intervention by primary care physicians for those with unhealthy alcohol use reduces risky consumption. Because of this, practice guidelines recommend universal screening."

The goal of this study was to validate a single-item screening test for unhealthy alcohol use recommended by the NIAAA.

Adult English-speaking patients recruited from primary care waiting rooms were asked, "How many times in the past year have you had X or more drinks in a day?" (X = 5 for men and 4 for women). A positive response to this single-question screen was defined as 1 or more. Patients were considered to have unhealthy alcohol use if a standardized diagnostic interview revealed the presence of an alcohol use disorder or if a validated 30-day calendar method showed risky consumption.

The interview was completed by 286 (73%) of 394 eligible primary care patients. For identification of unhealthy alcohol use, the single-question screen was 81.8% sensitive (95% confidence interval [CI], 72.5% - 88.5%) and 79.3% specific (95% CI, 73.1% - 84.4%). For identification of a current alcohol use disorder, the single-question screen was slightly more sensitive (87.9%; 95% CI, 72.7% - 95.2%) but was less specific (66.8%; 95% CI, 60.8% - 72.3%).

Test characteristics of the single-question screen resembled those of a commonly used 3-item screen. Subject demographics affected diagnostic performance of the single-question screen only minimally.

"The single screening question recommended by the NIAAA accurately identified unhealthy alcohol use in this sample of primary care patients," the study authors write. "These findings support the use of this brief screen in primary care."

Limitations of this study include refusal of almost half of the patients approached in the primary care waiting room to be screened for eligibility in the study; failure of approximately one fourth of eligible subjects to complete the study; report of substance use disorders in a higher-than-expected proportion of subjects, creating possible selection bias; and lack of validation of the single-question screen in languages other than English.

"The sensitivity and specificity of this single question was comparable to that reported for longer instruments in other studies," the study authors conclude. "These findings of validity support the use of this brief screen in primary care as recommended by NIAAA, which should, in turn, help with the implementation of universal screening for unhealthy alcohol use as recommended by national practice guidelines. Some patients who screen positive will have severe alcohol use disorders requiring referral to substance abuse treatment, while those who consume excessive amounts of alcohol but have not experienced severe health or interpersonal problems would benefit from brief intervention by the primary care provider."

The NIAAA supported this study. The study authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online March 12, 2009.

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