The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test.

OBJECTIVE: To evaluate the 3 alcohol consumption questions from the Alcohol Use Disorders Identification Test (AUDIT-C) as a brief screening test for heavy drinking and/or active alcohol abuse or dependence. METHODS: Patients from 3 Veterans Affairs general medical clinics were mailed questionnaires. A random, weighted sample of Health History Questionnaire respondents, who had 5 or more drinks over the past year, were eligible for telephone interviews (N = 447). Heavy drinkers were oversampled 2:1. Patients were excluded if they could not be contacted by telephone, were too ill for interviews, or were female (n = 54). Areas under receiver operating characteristic curves (AUROCs) were used to compare mailed alcohol screening questionnaires (AUDIT-C and full AUDIT) with 3 comparison standards based on telephone interviews: (1) past year heavy drinking (>14 drinks/week or > or =5 drinks/ occasion); (2) active alcohol abuse or dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, criteria; and (3) either. RESULTS: Of 393 eligible patients, 243 (62%) completed AUDIT-C and interviews. For detecting heavy drinking, AUDIT-C had a higher AUROC than the full AUDIT (0.891 vs 0.881; P = .03). Although the full AUDIT performed better than AUDIT-C for detecting active alcohol abuse or dependence (0.811 vs 0.786; P<.001), the 2 questionnaires performed similarly for detecting heavy drinking and/or active abuse or dependence (0.880 vs 0.881). CONCLUSIONS: Three questions about alcohol consumption (AUDIT-C) appear to be a practical, valid primary care screening test for heavy drinking and/or active alcohol abuse or dependence.

Detoxification recidivism among urban American Indian alcoholics.

Fifty urban American Indians were interviewed during admission to a free-standing medical detoxification unit. From the year before the interview through 2 years of follow-up, this sample averaged 44.6 detoxification admissions and 64.1 days in other inpatient treatment and had no significant change in the number of annual detoxification admissions. At follow-up all but three subjects reported recent alcohol dependence symptoms or episodic alcohol abuse. these patients continued to experience serious alcohol-related problems despite repeated treatment in both medical detoxification and inpatient rehabilitation settings. These findings emphasize the need for more innovative and effective alternatives to the existing revolving door process.

Secondary prevention with college drinkers: evaluation of an alcohol skills training program.

This study evaluated secondary prevention approaches for young adults (N = 36, mean age 23 years) at risk for alcohol problems. Subjects were randomly assigned to cognitive-behavioral alcohol skills training, a didactic alcohol information program, or assessment only. The skills program included training in blood alcohol level estimation, limit setting, and relapse prevention skills. All subjects maintained daily drinking records during the 8-week intervention and for 1 week at each follow-up. Repeated measures MANOVA found a significant reduction over 1-year follow-up in self-reported alcohol consumption for the total sample. For all drinking measures, the directional findings consistently favored skills training. Despite overall reductions, most subjects continued to report occasional heavy drinking.

An experimental test of three methods of alcohol risk reduction with young adults.

This study tested 3 forms of alcohol risk reduction programming for young adults. Volunteers were randomly assigned to receive a 6-week class and discussion group, a 6-unit self-help manual, or a single 1-hr feedback and advice session with professional staff. Results reveal significant reductions in self-reported drinking at the end of the intervention phase and maintenance of drinking changes throughout a 2-year follow-up period. Comparable drinking reductions were rated across treatments; however, noncompliance with the self-help reading program suggested limited utility. Treatment response was related to subject age, as subjects showed increased drinking during the year they reached legal drinking status. The efficacy of brief motivational interventions and client matching in prevention programs is discussed.

Individual drinking changes following a brief intervention among college students: clinical significance in an indicated preventive context.

This study investigated the clinical significance of previously reported statistically significant mean reductions in drinking and related problems among college students in a randomized trial of a brief indicated preventive intervention (G. A. Marlatt et al., 1998). Data were analyzed over a 2-year follow-up for participants from a high-risk intervention group (n = 153), a high-risk control group (n = 160), and a functional comparison group (n = 77). A risk cutpoint for each dependent measure was based on the functional comparison group distribution. Compared with the high-risk controls, more individuals in the high-risk intervention group improved and fewer worsened, especially on alcohol-related problems and, to a lesser extent, on drinking pattern variables. These data from a prevention context clarify the magnitude and direction of individual change obscured by group means.

Screening and brief intervention for high-risk college student drinkers: results from a 2-year follow-up assessment.

This randomized controlled trial evaluated the efficacy of a brief intervention designed to reduce the harmful consequences of heavy drinking among high-risk college students. Students screened for risk while in their senior year of high school (188 women and 160 men) were randomly assigned to receive an individualized motivational brief intervention in their freshman year of college or to a no-treatment control condition. A normative group selected from the entire screening pool provided a natural history comparison. Follow-up assessments over a 2-year period showed significant reductions in both drinking rates and harmful consequences, favoring students receiving the intervention. Although high-risk students continued to experience more alcohol problems than the natural history comparison group over the 2-year period, most showed a decline in problems over time, suggesting a developmental maturational effect.

Outcome of contingency contracting for illicit drug use in a methadone maintenance program.

This study evaluates the outcome of a mandatory, clinic wide, structured contingency contracting system in a methadone maintenance program. The system involved weekly urine screening and placement on written individualized contracts for any of 106 male patients who displayed illicit drug use. Methadone dose decreases were the penultimate and detoxification and discharge the ultimate contingencies for unremitting drug use. Sixty subjects (56.6%) received contracts and 36 (35%) eventually left treatment. The contracts did not decrease the overall number of positive urines for the contract subjects, but opiate use did decrease significantly for subjects on more stringent contracts.

The Alcohol Skills Training Program: a group intervention for young adult drinkers.

Development, content, and evaluation of the Alcohol Skills Training Program (ASTP) is described. Patterned after strategies for relapse prevention, the ASTP is a cognitive behavioral approach to the secondary prevention of alcohol problems. Format and context of the six group sessions are detailed, and process considerations are discussed. Results are summarized for two controlled investigations of the ASTP with young adult drinkers. The psychoeducational approach of the ASTP is recommended as an effective means for changing drinking patterns among young adults who are at risk for alcohol-related problems.

Integrating skills training and motivational therapies. Implications for the treatment of substance dependence.

Two well-articulated models of substance abuse treatment, skills training and motivational enhancement, have received considerable research attention in recent years. Skills training treatments operate on the underlying rationale of correcting skills deficits, whereas motivational strategies are based on affecting clients' willingness to use skills they already possess. Skills training and motivational enhancement are typically described as distinct treatments and have recently been constructed as different treatments within a large multisite trial in the United States (Project MATCH). This article explores how treatments for substance abuse can draw from and integrate skills training and motivational strategies. Recovery from addictive patterns of behavior often requires learning over time and typically involves slips, relapses, and multiple quit attempts. Therapeutic support for change in addictive behavior, in particular attempting to prevent and minimize relapse, requires assessment and support of both why one might pursue change (motivation) and how one can best be successful (skills).

Trauma, symptoms of posttraumatic stress disorder, and associated problems among incarcerated veterans.

OBJECTIVE: To help improve treatment for incarcerated veterans, the study examined exposure to trauma, symptoms of posttraumatic stress disorder (PTSD), functional status, and treatment history in a group of incarcerated veterans. METHODS: A convenience sample of 129 jailed veterans who agreed to receive outreach contact completed the Life Event History Questionnaire, the PTSD Checklist-Civilian Version (PCL-C), and the Addiction Severity Index. Participants who had scores of 50 or above on the PCL-C, designated as screening positive for PTSD, were compared with those whose scores were below 50, designated as screening negative for PTSD. RESULTS: Some 112 veterans (87 percent) reported traumatic experiences. A total of 51 veterans (39 percent) screened positive for PTSD, and 78 veterans (60 percent) screened negative. Compared with veterans who screened negative for PTSD, those who screened positive reported a greater variety of traumas; more serious current legal problems; a higher lifetime use of alcohol, cocaine, and heroin; higher recent expenditures on drugs; more psychiatric symptoms; and worse general health despite more previous psychiatric and medical treatment as well as treatment for substance abuse. CONCLUSIONS: The findings encourage the development of an improved treatment model to keep jailed veterans with PTSD from repeated incarceration.

Binge drinking among female Veterans Affairs patients: prevalence and associated risks.

This study evaluated the prevalence and associated risks of binge drinking, defined as having > or = 4 drinks on an occasion in the past year, in a female patient population. Of 1,259 female Veterans Affairs patients surveyed, 780 reported drinking alcohol in the past year, and 305 (24% of respondents, 39% of drinkers) reported binge drinking in the past year; 84 (11% of drinkers) had done so monthly or more often. Age-adjusted logistic regression analyses indicated that women who reported past-year binge drinking monthly or more often reported significantly increased odds of morning drinking (odds ratio [OR] = 40.3), others worrying about their drinking (OR = 38.6), arguments after drinking (OR = 13.5), hepatitis or cirrhosis (OR = 3.1), frequent injuries (OR = 2.6), smoking (OR = 3.7), drug use (OR = 22.2), and multiple sexual partners (OR = 4.6).

Derivation and validation of neuropsychological clusters among men alcoholics.

Scores from 13 cognitive-neuropsychological tests administered to 245 men alcoholics were subjected to an average linkage cluster analysis. Six subtypes were derived but three were eliminated from further analyses because they had samples of less than 10. The remaining clusters appeared to reflect differing levels and patterns of neuropsychological functioning. Subsequent analyses indicated that the clusters were related to age but were independent of most other demographic and pretreatment alcohol-related variables. Significant associations were found between cluster membership and the likelihood of abstinence, completion of aftercare therapy and employment status over a 9-month follow-up period. Although this relationship to outcome is encouraging, neuropsychological status accounted for only a limited amount of the variance. The findings suggest the need to broaden the base of assessment, using multiple domains, in future attempts to derive meaningful subtypes within an alcoholic population.

The Alcohol Dependence Scale: a validation study among inpatient alcoholics.

The present study investigated whether the degree of alcohol dependence, as operationalized by Skinner and Allen's Alcohol Dependence Scale (ADS), covaried with concurrent and predictive criteria in a sample of hospitalized alcoholics. As previously reported, the ADS was found to be unidimensional and internally consistent. However, compared to Skinner and Allen's findings, these inpatients had significantly lower ADS scores. Correlations with concurrent measures of cognitive functioning, psychiatric and physical symptoms tended to be smaller than, but in the same direction as, those previously reported using an outpatient sample. ADS scores did not significantly predict attrition from inpatient treatment, self-reported alcohol consumption over 9-month follow-up or duration of aftercare involvement. Patients who relapsed reported significantly higher ADS scores at admission, however, the magnitude of this relationship was modest (r = .16). In its present form, the ADS appears to have fair concurrent validity, but limited predictive utility within a sample of inpatient alcoholics.

The relationship between alcohol screening questionnaires and mortality among male veteran outpatients.

OBJECTIVE: This study evaluated whether responses to alcohol screening questionnaires predicted mortality in a Department of Veterans Affairs (VA) primary care population. METHOD: This study involved 5,703 male outpatients (mean age = 64) who were enrolled in General Internal Medicine clinics at three Veterans Affairs (VA) medical centers and returned mailed questionnaires in 1993-94. The two questionnaires included the CAGE and Alcohol Use Disorders Identification Test (AUDIT) alcohol screening tests. Mortality was ascertained using the VA Beneficiary Identification and Record Locator System. Five-year crude and adjusted mortality rates were calculated for patients who screened positive and patients who screened negative on each alcohol screening test. RESULTS: The risk of mortality was increased among drinkers who scored > or = 8 on the full AUDIT (hazard ratio: 1.47; 95% confidence interval [CI]: 1.08-2.00) or the three AUDIT consumption questions (1.58; 1.11-2.27), after adjusting for age, smoking, sociodemographic characteristics and chronic illnesses. The risk of mortality was also increased among drinkers who reported drinking > or = 3 drinks daily (1.69; 1.28-2.22) or prior alcohol treatment (1.66; 1.27-2.17), in "fully adjusted" models. A positive CAGE score (> or = 2) was associated with significantly increased risk of mortality among drinkers in a model adjusted only for age and smoking (1.27; 1.02-1.58). Among nondrinkers, neither a positive CAGE score (> or = 2) nor report of prior alcohol treatment was associated with increased risk of mortality. CONCLUSIONS: VA outpatients who reported drinking during the previous year and who had a positive result on an alcohol screening test experienced higher mortality over the subsequent 5 years than did patients who screened negative.

Correlates of alcohol consumption: sex, age, and expectancies relate differentially to quantity and frequency.

Expectations of the effects of alcohol have been related to drinking behaviors for both problem and nonproblem drinkers. The present investigation expanded on previous research by considering age, sex, and alcohol expectancies as differential predictors of frequency and quantity of drinking. Subjects, 157 males and 168 females, completed alcohol expectancy, drinking habits, and demographic questionnaires. Results showed significant sex differences in predictors of drinking frequency. Males who reported most frequent drinking tended to have stronger expectations of increased Social and Physical Pleasure, Global Positive Changes, and Sexual Enhancement. On the other hand, frequent consumption among females was best predicted by stronger expectations that alcohol would reduce tension. The amount consumed per drinking occasion was predicted by the same two expectancy factors for males and females: Social and Physical Pleasure and Social Assertion. Age was an important contributing predictor of quantity and frequency for females only. Results indicated the importance of investigating the mediating role of expectancies (a) within sex and (b) with respect to frequency versus quantity of drinking behavior.

Predictors of relapse: interaction of drinking-related locus of control and reasons for drinking.

Pretreatment scores from the drinking-related locus of control scale (DRIE) and reasons for drinking were investigated as predictors of drinking relapse over a nine-month follow-up in a sample of 232 male alcoholics. A significant relationship was found between reasons for drinking and the probability of relapse, with the lowest relapse rates occurring among patients who identified interpersonal conflicts or positive emotional states as the most important reasons for their pretreatment drinking. Results of a reasons for drinking by relapse status ANOVA on DRIE scores revealed no significant main effects. There was, however, a significant interaction. Among patients who attributed their drinking to negative emotional states, those who either relapsed or were lost to follow-up had significantly more external DRIE scores. Among patients who identified negative physical states (i.e., craving) as their primary reason for drinking, relapse or attrition was associated with significantly more internal DRIE scores. Results support assessment of these cognitive social learning constructs for differential treatment planning with patients at increased risk of relapse.

Alcoholic subtypes based on multiple assessment domains. Validation against treatment outcome.

Research in the area of subtype development within alcoholic populations has undergone a number of changes over the recent years. First, there has been a shift from subtype derivation based on a priori comparative approaches toward a more recent use of a posteriori correlational approaches such as cluster analysis. Second, there has been an increased multivariate focus in which multiple measures from a number of practically and/or theoretically relevant assessment domains are entered into the classificatory process. Third, there has been an increased emphasis on the external validation of derived clusters. The present chapter briefly reviews these issues, using examples of research from the Seattle Veterans Administration Medical Center to illustrate each of these shifts across a series of studies focusing on the development of alcoholic subtypes. Finally, the results of a recent subtype identification and validation study will be presented to illustrate the difficulties in and advantages of a multidomain cluster analytic strategy.

Alcohol abuse in urban Indian adolescents and women: a longitudinal study for assessment and risk evaluation.

Empirical studies of American Indian health and mental health have focused primarily on reservation samples or small cross-sectional school-based or treatment samples. Few studies have addressed these issues among urban American Indian populations. This paper introduces an ongoing ten-year prospective longitudinal study of alcohol abuse, drug abuse, and mental health status in a community sample of urban American Indian adolescents and women. The study uses structured interviews and diagnostic assessments to identify risk factors for, and measure prevalence of, alcohol abuse, drug abuse, and psychopathology in 523 Indian youth and 276 Indian women. Study aims, rationale, research design, methods, sample characteristics, assessment instruments, and substance use prevalence are described, and methodological issues related to conducting longitudinal research are discussed.

Predicting ongoing adherence to disease modifying therapies in multiple sclerosis: utility of the health beliefs model.

OBJECTIVE: To evaluate ongoing adherence to disease modifying therapies (DMT) among individuals with multiple sclerosis and test the utility of the Health Beliefs Model (HBM) to predict adherence. DESIGN: Telephone survey completed at baseline with monthly telephone follow-up for 6 months. SETTING: Veterans Health Administration. PARTICIPANTS: Eighty-nine veterans with MS actively enrolled in a regional VA MS outpatient clinic currently prescribed DMT. MEASURES: Demographic information. Selected items from the Adherence Determinants Questionnaire (ADQ) and Barriers to Care Scale (BACS). RESULTS: Adherence in this population of ongoing DMT users was relatively high (over 80% achieved 80% adherence at follow-up time points). Logistic regression and hierarchical multiple regression analyses controlling for demographics and disease duration were employed to examine the relationship of HBM constructs of perceived susceptibility, severity, benefits, and barriers to DMT adherence and satisfaction at 2-, 4- and 6-month follow-up. Of the four HBM constructs, only perceived benefits uniquely predicted both outcomes across multiple time points. CONCLUSION: Sustained adherence to DMT remains a challenge for an important minority of individuals with MS. The Health Beliefs Model provides insight into psychosocial mechanisms that maintain adherence behavior. In particular, focus upon the perceived benefits of ongoing DMT therapy may be a promising focus for future interventions.