Until the mid-1980’s, the 4-item CAGE (Ewing, 1984
) was the only brief alcohol screening instrument available. In the early-1990’s, the Alcohol Use Disorders Identification Test (AUDIT) was developed and was found to be the best “brief” screening instrument for use among adults (Saunders et al., 1993
). However, the AUDIT is relatively long and uses a relatively complicated scoring system (10 questions, range 0=40 points). During the last 20 years, alcohol research has seen a burgeoning of that focus on the development of very brief screening instruments for the identification of hazardous drinking and alcohol use disorders (AUD) in primary care settings studies (e.g., Cherpitel, 1999; Hodgson et al., 2003
; Knight et al., 1999
; Russell et al., 1989, Saunders et al., 1993
). ). Ease and brevity in administration are assets for alcohol screens used in the ED, yet few studies have directly compared the performance of the briefest of these alcohol screens to determine their suitability for use with young adults in an ED setting. Evaluation of these instruments usually focuses on their sensitivity (ability to identify true positive cases) and their specificity (ability to identify true negative cases).
Recently, a short version of the AUDIT (the AUDIT-C) that uses only the consumption items (Items 1–3; range 0–12) (AUDIT-C) was found to accurately identify 84% of ED patients with a DSM-IV defined alcohol abuse or alcohol dependence disorder, while correctly classifying 74% of those patients without an AUD, using a cut-point of 4 (Dawson et al., 2005
). At a cut-point of 5, the AUDIT-C was 78% sensitive and 79% specific for identifying AUD among people in the 18–29 year old age group. Although the AUDIT-C is much shorter than the full AUDIT, its 12-point scoring system is still somewhat unwieldy.
A screening instrument developed for use in ED, the RAPS4 assesses remorse over drinking, alcoholic blackouts, impairment in completing responsibilities, and drinking in the morning. The RAPS4 has been shown to be effective for identifying adult ED patients with alcohol dependence, but was less useful for detecting alcohol abuse (Cherpitel, 1995
). A version of the RAPS4, the 6-item RAPS4-QF, which also assesses alcohol consumption, however, can identify 90% of alcohol abuse cases while correctly identifying 82% of alcohol abuse non-cases among adults treated in emergency departments (Cherpitel, 2002
The CRAFFT (Knight et al., 1999
) is a mnemonic for six items that describe use of drugs to relax, use of drugs when alone, driving using drugs or riding with a drug using driver, family or friends concern about drug use, and experiencing negative consequences of drinking or use of drugs. The CRAFFT has been found to have good discriminative properties for determining the presence of substance use disorders among 14–18 year old adolescents in primary care (Knight et al., 2002
The 4-item Fast Alcohol Screening Test (FAST), developed by Hodgson and colleagues (2002)
in an Accident and Emergency Department using items borrowed from the AUDIT (see section 2.5 for item descriptions). The FAST was found to be 93% sensitive and 88% specific for identifying alcohol “misuse” when a cut-point of 3 or higher is used.
Our own previous work identified a 5-item screening instrument based on selected items from the AUDIT, CRAFFT, and CAGE called the RUFT-Cut. The RUFT-Cut performed as well as the full scale AUDIT (sensitivity = 82%, specificity = 78%; Kelly et al, 2004
). The RUFT-Cut was validated in a small sample, however, and these findings were considered preliminary. The current study uses a sample size that increases the original sample by 95%.
Other research efforts using a minimal number of questions have found that such very brief screens can still be sensitive for identifying patients with alcohol use disorders, but may sacrifice some degree of specificity for identifying non-cases (Canagasaby & Vinson, 2005; Dawson et al., 2005
; Vinson et al., 2007
). Vinson and colleagues (2005), for example, found over 90% sensitivity but only 77% specificity for identifying AUD cases using just two-items from the larger set used to define DSM-IV alcohol abuse or dependence, specifically, “recurrent drinking in hazardous situations” and “drinking more tan intended, or over a longer period than intended.”
Although many efforts to develop screening instruments have included young adult patients (aged 18–24 years), few have focused on young adult under-aged drinkers aged 18–20 years treated in emergency departments. Nationally, 89,000 young adults between 18 and 20 years of age were treated in ED for alcohol-related illness or injury in the last six months of 2005 (Drug Abuse Warning Network, 2007). Research shows that the earlier young patients who are experiencing AUD are identified, the more quickly treatment is provided and negative outcomes are prevented in this high-risk population (Godley and White, 2005
). Furthermore, cost-effectiveness research indicates that intervention is beneficial in primary care clinics where specific sub-groups such as patients with mild to moderate alcohol abuse can be efficiently targeted (Chisholm et al., 2004
Efforts for identifying alcohol-related problems in EDs often involve a brief intervention component for reducing use (e.g., Monti et al., 1999
). Such efforts often include assessment of what is considered hazardous use or risk drinking, i.e., males drinking more than 14 drinks a week, females drinking more than 7 drinks, or males drinking more than 4 drinks at a time once a month or more, females drinking more than 3 drinks at a time once a month or more (US Department of Health and Human Services, 2005
). Our project did not include conducting brief treatment in the emergency department. Rather it consisted of collecting screening data in the ED with recommendations for a full psychiatric evaluation within the next week. Because we were not providing brief interventions in the ED we did not focus on hazardous or risk drinking. Conversely, because the feedback we provided to the participant at the time of the follow-up study was related to the findings on the SCID-IV (Spitzer et al, 1992
), we did focus on assessment of alcohol use disorders.
The objective of the current study is to test the utility of six very brief screening instruments for identifying AUD in a sample of 181 young adults in the hectic environment of an emergency department. The instruments included in this study are the RUFT-Cut, the CRAFFT, the FAST, the RAPS4-Q, the AUDIT-C, and the DSM-IV-2-Item Scale.