Screening

Screening is a preliminary procedure used to determine the likelihood that an individual has a particular disease or condition or is at increased risk of developing health or social problems. Screening for alcohol use by patients in health care settings can have four distinct purposes:

• Assessment of current intoxication to guide clinical management of acute injuries and illnesses;
• Assessment of current intoxication to guide medical management of alcohol intoxication;
• Determination of alcohol use patterns to guide treatment or referral to treatment for alcohol problems; and
• Assessment of intoxication at the time of injury to assist law enforcement and public safety (as mandated in several states).
• Decreasing any inherent bias or prejudice for or against a patient because of gender, sexual orientation, ethnic or cultural stereotypes.

Selecting screening tools must be guided by the primary purpose for which the tools will be used. For the acute medical management of traumatic injuries, assessment of current intoxication is critical and assessment of current alcohol use disorder diagnosis is less important. For this purpose, biological assessments (e.g., blood alcohol concentration) may be the most appropriate screening tool. To guide a brief intervention intended to reduce hazardous use of alcohol or other drugs, however, measuring current intoxication may be less important than assessing patterns of hazardous alcohol or drug use. Determining whether a patient is dependent on alcohol or other drugs may also be a critical guide for the development of discharge plans and referral to specialty substance use disorders treatment. Standard "NIDA 5" urine toxicology screens are inadequate for screening for substance use unless there is a method for rapid testing for semi-synthetic and synthetic opioids, benzodiazepines, barbiturates, methylphenidate and other substances commonly used.

Self-report screening questionnaires: An extensive set of brief, self-report or interviewer-directed screening questionnaires such as CAGE have been validated in emergency settings and primary care practice for alcohol use, and a smaller number have been validated for illicit drug use. Descriptions of many of the most commonly used instruments and their psychometric properties have been summarized by NIAAA. The majority of self-report questionnaires take 5 minutes or less to administer and they show high levels of sensitivity and specificity, when validated against structured diagnostic interviews and biological assays. Several of the questionnaires are substantially better at detecting current alcohol use disorders and hazardous and harmful use than clinician judgment or biological assays such as blood alcohol concentration (BAC) or drug toxicology screen. Studies in hospital emergency departments find few patients refuse to take the screening tests, although rates of 15% to 30% of patients unable to be administered the tests are common in trauma centers (e.g., patients with brain injuries, intubation, rapid discharge to other services, or non-English speaking). The screening questionnaires have been administered by physicians, nurses, substance use treatment counselors, and health educators with comparable success.

Biological assays: Biological assays using blood or saliva can reliably identify current intoxication and recent past use, but are insensitive to past history of hazardous use or dependence, and to alcohol use at the time of injury if the time interval is too long. Information about current intoxication can be clinically useful for management of patients’ injuries. It can also be useful for identifying patients who were impaired by alcohol at the time of their injury and may be candidates for brief interventions. However, BAC is not a sensitive tool for identifying emergency services patients who have a pre-existing alcohol use disorder because they may not be intoxicated at the time of presentation. Blood indices such as MCV, AST, ALT and GGT would be more useful.

Clinical impression: Clinicians often use their general impression to help with diagnosis. Clinical impressions concerning alcohol problems, however, have been shown to be very imprecise. Primary care physicians and emergency physicians using their clinical judgment alone correctly identify fewer than 50% of patients with alcohol problems. Gentilello and his colleagues found that trauma center staff incorrectly suspected alcohol intoxication in 26% of patients who screened negative on structured questionnaires and had a blood alcohol concentration of zero. Physicians correctly identified only 77% of patients who were acutely intoxicated. Over half of the patients who screened positive for chronic alcohol abuse or dependence were not suspected of having an alcohol problem by either physicians or nursing staff. Physicians and medical personnel are also particularly unsuccessful in using their clinical impression to accurately detect alcohol intoxication in patients who were who have closed head injuries, which are endotracheal intubated, or severely injured and in pain. Physicians and healthcare personnel are not immune to alcohol and substance misuse and have a slightly higher risk for abuse and dependence than the general population. Training the medical profession in screening and brief intervention will result in a certain population of professionals who become more aware of their own misuse or need for help. The healthcare professional's heightened awareness of the risks of misuse would be expected to increase their wish to help the adolescent who is 'experimenting' with alcohol and/or drugs and increase their compassion towards the patient in the latter stages of addiction.

References:

• Gentilello L, Villaveces A, Ries RR et al (1999) Detection of acute alcohol intoxication and chronic alcohol dependence by trauma center staff. J Trauma, 47: 1131-9.

• NIAAA (2002). Screening for Alcohol Problems: An Update, Alcohol Alert. 56. http://pubs.niaaa.nih.gov/publications/aa56.htm

• Connors GJ & Volk RJ (2004) Self-report screening for alcohol problems among adults. NIAAA, http://pubs.niaaa.nih.gov/publications/Assesing%20Alcohol/selfreport.htm

• Rydon P, Redman S, Sanson-Fisher R, Reid A (1992) Detection of alcohol-related problems in general practice. J Stud Alcohol, 53: 197-202.

• Babor TF, Kadden RM (2005). Screening and interventions for alcohol and drug problems in medical settings: What works? J Trauma; 59(3 Supp):S80-7.

• Gentilello LM, Ebel BE, Wickizer TM, Salkever DS, Rivara FP (2005) Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis. Ann Surg. 2005 Apr;241(4):541-50.