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. Author manuscript; available in PMC: 2015 Jun 1.
Published in final edited form as: Drug Alcohol Depend. 2014 Apr 5;139:178–180. doi: 10.1016/j.drugalcdep.2014.03.027

Use of a single alcohol screening question to identify other drug use

Peter C Smith 1,*, Debbie M Cheng 2,3, Donald Allensworth-Davies 4, Michael R Winter 5, Richard Saitz 1,2,6
PMCID: PMC4085274  NIHMSID: NIHMS584378  PMID: 24768061

Abstract

Background

People who consume unhealthy amounts of alcohol are more likely to use illicit drugs. We tested the ability of a screening test for unhealthy alcohol use to simultaneously detect drug use.

Methods

Adult English speaking patients (n=286) were enrolled from a primary care waiting room. They were asked the screening question for unhealthy alcohol use “How many times in the past year have you had X or more drinks in a day?”, where X is 5 for men and 4 for women, and a response of one or more is considered positive. A standard diagnostic interview was used to determine current (past year) drug use or a drug use disorder (abuse or dependence). Oral fluid testing was also used to detect recent use of common drugs of abuse.

Results

The single screening question for unhealthy alcohol use was 67.6% sensitive (95% confidence interval [CI], 50.2%- 82.0%) and 64.7% specific (95% CI, 58.4%- 70.6%) for the detection of a drug use disorder. It was similarly insensitive for drug use detected by oral fluid testing and/or self-report.

Conclusions

Although a patient with a drug use disorder has twice the odds of screening positive for unhealthy alcohol use compared to one without a drug use disorder, suggesting patients who screen positive for alcohol should be asked about drug use, a single screening question for unhealthy alcohol use was not sensitive or specific for the detection of other drug use or drug use disorders in a sample of primary care patients.

Keywords: Screening, alcohol, drug use, primary care

1. Introduction

Both unhealthy alcohol and drug use (the spectrum of use that risks health consequences through substance use disorders) are common in primary care and underdiagnosed (Cherpitel and Ye, 2008; Saitz et al., 1997). There are a number of screening tests for these conditions, including single screening questions for alcohol and for other drugs, both of which have been validated in the primary care setting (Smith et al., 2009, 2010). The U.S. Preventive Services Task Force (USPSTF) recommends screening and brief intervention for unhealthy alcohol use, and not for other drug use (USPSTF, 2008), in part because the efficacy of brief intervention for other drugs is uncertain. They also note that under some clinical circumstances (e.g., risk factors, high prevalence) screening and intervention might be useful.

People with unhealthy alcohol use are also more likely than those without unhealthy alcohol use to use illicit drugs or misuse psychoactive prescription drugs; as such, a screening test for unhealthy alcohol use might provide information about other drug use and allow clinicians to screen for both conditions simultaneously (Dawson et al., 2010). If true, this would provide an elegant, efficient solution to the dilemma of whether or not to screen for the less prevalent, but nonetheless clinically important, problem of other drug use. We therefore studied the test operating characteristics of a single screening question for unhealthy alcohol use (the question recommended by the National Institute on Alcohol Abuse and Alcoholism) to detect other drug use (Smith et al., 2009).

2. Methods

This study is a secondary analysis of data collected originally for the purpose of determining the validity of single screening questions for alcohol and drug use in primary care (Smith et al., 2009, 2010).

2.1 Participants

The study was conducted between October, 2006 and June, 2007 at an urban safety-net hospital-based primary care clinic at an academic medical center. The participant selection and data collection methods have been described previously (Smith et al., 2009). A sample of waiting room patients was selected by a research associate who systematically approached those waiting to be seen according to a predetermined pattern based on waiting room seating; this pattern was varied daily. Patients under the age of 18 were excluded as were those who, in the judgment of the research associate, would be unable to complete the questionnaire because of limited English, cognitive impairment or acute illness. People in the waiting room accompanying patients who reported not being patients of the clinic themselves were also excluded. The Institutional Review Board of Boston University Medical Center approved the study.

2.2 Data collection

Interviews were conducted by trained research staff in a private setting and data were recorded anonymously. Participants were first asked the single screening question, “How many times in the past year have you had X or more drinks in a day?” (where X is 5 for men and 4 for women). They were then assessed by interview for 1) lifetime drug consequences or problems using the Short Inventory of Problems-Drug Use (SIP-DU) questionnaire (Saitz et al., 2009); 2) current (past year) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) drug use disorder (abuse or dependence) using the computerized Composite International Diagnostic Interview (CIDI) Substance Abuse Module (Kessler et al., 2004); and 3) current (past year) use of illicit drugs (marijuana, cocaine, heroin, stimulants or hallucinogens) and non-medical use of prescription drugs using CIDI questions. After the interview (without previously having been informed) participants were asked (a second informed consent process) to undergo oral fluid testing for opioids, benzodiazepines, cocaine, methamphetamines, and tetrahydrocannabinol (THC). Oral fluid was tested by Intercept™ immunoassay (OraSure Technologies, Bethlehem, PA). This assay has comparable, and (with respect to heroin and cocaine) possibly superior, test characteristics when compared to standard urine drug screening (Cone et al., 2002). After 23 participants had been enrolled, we added an interview item to assess recent prescription of opioids or benzodiazepines.

2.3 Reference standard

Participants were considered to have current drug use if, during the CIDI, they reported the use of an illicit drug (marijuana, cocaine, heroin, stimulants or hallucinogens), or a prescription drug for non-medical reasons. A complementary analysis was done using a reference standard of a positive self-report or a positive oral fluid test. Oral fluid tests were positive if cocaine, THC, or methamphetamines were detected, or if opioids or benzodiazepines were detected and the participant had not reported a recent opioid or benzodiazepine prescription. Drug problems were defined as current drug use and a positive response to any of the 15 SIP-DU questions. Current drug disorder (abuse or dependence) and drug dependence were defined by the CIDI among participants with symptoms in the past 12 months.

2.4 Statistical analysis

We calculated the sensitivity, specificity, likelihood ratios and area under the receiver operating characteristic curve (AUC) of the single-question screen for the detection of drug use, drug use associated with problems or a current drug use disorder, a current drug use disorder, and drug dependence (Hanley and McNeil, 1982). For sensitivity and specificity, we calculated 95% exact binomial confidence intervals, for likelihood ratios 95% confidence intervals were calculated using published formulas (Altman and Gardner, 1992). Statistical analyses were performed using Version 9.1 of the SAS System (copyright SAS Institute Inc.).

3. Results

3.1 Participant characteristics

Participant recruitment and participant characteristics are detailed elsewhere (Smith et al., 2009). Briefly, 73% of eligible patients completed interviews and had their data analyzed. Of these 286 participants, 54% were women, and the median age was 49 (range 21-86). The majority of participants (63%) identified themselves as Black or African-American. The prevalence of past-year drug use by self-report was 35% (32% reported at least one problem relating to use). Of the 217 who consented to oral fluid testing and answered the added questions about prescribed opioids and benzodiazepines, 40% either reported drug use or had a positive test (38% of the 217 reported problems associated with their use). The prevalence of a drug use disorder was 13%, alcohol use disorder 12%; 31% had unhealthy alcohol use (use of risky amounts, presence of problems or an alcohol use disorder).

3.2 Test operating characteristics

The single-question screen at a cut-off of one or more times (the value considered a positive test for alcohol screening) was 67.6% sensitive (95% confidence interval (CI), 50.2%- 82.0%) and 64.7% specific (95% CI, 58.4%- 70.6%) for the detection of a current drug use disorder (Table). It appeared slightly less sensitive (62.6%; 95% CI, 52.3%- 72.2%) and more specific (72.7%; 95% CI, 65.8%- 79.0%) for the detection of current drug use (although CIs overlapped). If oral fluid test results were taken into account, the sensitivity for detecting current drug use was lower (58.8%; 95% CI, 47.6%- 69.4%) and the specificity higher (80.3%; 95% CI, 72.5%-86.7%). Additional test operating characteristics appear in the Table.

Table 1. Test Operating Characteristics of a Single Alcohol Screening Question for the Detection of Drug Use, Problems and Disorders in Primary Care Patients.

For detection of: Sensitivity (95% CI) Specificity (95% CI) Positive LR (95% CI) Negative LR (95% CI) AUC*
Current drug use, self-reported (n=286) 62.6% (52.3%, 72.2%) 72.7% (65.8%, 79.0%) 2.3 (1.7, 3.0) 0.5 (0.4, 0.7) 0.67
 With drug problem or drug use disorder 60.2% (50.1%, 69.7%) 72.1% (65.0%, 78.5%) 2.2 (1.6, 2.9) 0.6 (0.4, 0.7) 0.66
Current drug use, either self-report or a positive oral fluid test (n=217**) 58.8% (47.6%, 69.4%) 80.3% (72.5%, 86.7%) 3.0 (2.0, 4.4) 0.5 (0.4, 0.7) 0.70
 With drug problem or drug use disorder 60.8% (49.1%, 71.6%) 79.7% (72.0%, 86.1%) 3.0 (2.0, 4.4) 0.5 (0.4, 0.6) 0.71
Current drug use disorder (n=286) 67.6% (50.2%, 82.0%) 64.7% (58.4%, 70.6%) 1.9 (1.4, 2.5) 0.5 (0.3, 0.8) 0.58
Current drug dependence (n=286) 67.6% (49.5%, 82.6%) 64.3% (58.0%, 70.2%) 1.9 (1.4, 2.5) 0.5 (0.3, 0.8) 0.57
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CI=confidence interval, LR=likelihood ratio

*

The area under the receiver operating characteristic curve is a measure of a test's ability to discriminate between two conditions. An AUC of 1 represents perfect ability, and 0.5 a test no better than chance.

**

see Methods

4. Discussion

The single screening question for unhealthy alcohol use was not sensitive or specific for the detection of other drug use or drug use disorders in a sample of primary care patients. These limitations and the availability of other more sensitive brief screens argue against its use in high prevalence settings where screening for drug use is indicated. However, since the likelihood ratio for a positive alcohol screening test was 2-3 for drug use or disorder, these results suggest that patients who screen positive for unhealthy alcohol use have a higher likelihood of drug use. In settings where screening for alcohol use would be indicated, but drug use would otherwise not be, the results of this study indicate that clinicians should ask about drug use during a further assessment of this positive alcohol screen.

Current guidelines recommend screening for unhealthy alcohol use in primary care, but do not recommend routine screening for drug use because of limited evidence for efficacy (USPSTF, 2008). They do, however, recognize that there may be clinical circumstances in which screening might be considered. One randomized trial found a small effect of brief intervention in outpatient settings, though many were not primary care, and results at the US site were negative (Humeniuk et al., 2012). With limited evidence supporting the practice and primary care clinicians already under pressure to provide many preventive services during a short office visit (Yarnall et al., 2003), long and complicated screening tests will not facilitate drug screening in primary care. Even one single item for alcohol and another for drug may be too much.

One way to make screening more efficient is to use a single alcohol screening question to also screen for drug use, based on the fact that many people who use drugs also drink heavily (Dawson et al., 2010). Primary care clinicians already screen patients for unhealthy alcohol use (or should be doing so), and this strategy would allow them to also screen for drug use with less additional burden. Such an approach could facilitate screening in places or circumstances in which screening is desired (e.g., when prevalence is high). A national household survey estimated the accuracy of a question about heavy drinking similar to the one we studied, for the detection of drug use (Dawson et al., 2010). While their results were encouraging (area under the receiver operating characteristic curve (AUC) 0.83 for the detection of a drug use disorder), we did not confirm that level of accuracy in the primary care setting where such a test would be used (AUC 0.58). Addressing drug use only in those who screened positive for alcohol use would miss a substantial portion (37%) of current drug users. Its lack of specificity would also burden providers with the task of asking follow up questions about drug use to a large number of non-drug-using unhealthy alcohol users, though in a high prevalence population, this would be less of a problem as the predictive value of a positive test would be greater.

Other brief alcohol screens have, in general, test characteristics similar to the single alcohol screening question and so are likely to have similar limitations as screening tests for drug use (Smith et al., 2009). Conjoint screens (that ask questions about both alcohol and drugs in the same question items) might improve sensitivity but would add to the burden of follow-up questions, as all identified as positive need to be asked about both alcohol and drug use to determine which is present (Vinson et al., 2007). The ASSIST-Lite was found to be accurate, though its length (4 to 12 questions on drug use, depending on responses) may limit its utility in primary care, a setting in which it also has yet to be validated (Ali et al., 2013). A single drug screening question was 93% sensitive and 94% specific for the detection of current drug use, and may be the most efficient means of screening for drug use, when indicated, of those currently available (Smith et al., 2010). The question is currently recommended by the National Institute on Drug Abuse (National Institute on Drug Abuse, 2012).

One limitation of this study was its use of data from a sample of patients at one site at which there was a high prevalence of unhealthy alcohol and other drug use. Although the prevalence of disease traditionally does not affect sensitivity or specificity (it would affect predictive value), it is possible that this limitation (high prevalence of drug use, and overlap of those with both unhealthy alcohol and drug use) could have biased the study towards finding better operating characteristics of the test than if the study were done in a clinic with a lower prevalence. In locales where patterns of drug and alcohol use are such that individuals use one or the other more exclusively, the single alcohol screening question would be expected to be even less accurate. Also, although the CIDI is often used as a reference standard, there are other options (e.g., clinical interview) that might yield different results.

In summary, a screening test for unhealthy alcohol use that could also accurately detect drug use could facilitate drug use screening. We found that a positive response to such a test increases the likelihood that other drug use is present. However, our study found that a single alcohol screening question was not sufficiently sensitive or specific for the detection of drug use in primary care patients.

Acknowledgments

Role of Funding Source: This research was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism: NIAAA R01-AA010870; the NIAAA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Footnotes

Contributors: Authors Smith and Saitz designed the study and wrote the protocol. Authors Cheng, Allensworth-Davies and Winter undertook the statistical analysis, and author Smith wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of Interest: All authors declare they have no conflicts of interest.

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