Comparing screening instruments for alcohol dependence and abuse

  • The usefulness of many screening instruments for alcohol-use disorders may be limited to certain populations.
  • New research compares the performance of a two short screening instruments, RAPS4 and CAGE, against established criteria for alcohol dependence and abuse.
  • RAPS4 outperformed CAGE among the population examined.
  • When quantity-frequency (QF) questions were added, the RAPS4-QF performed even better for alcohol abuse.

Despite the challenges of living in an excessively busy world, clinicians do not have the luxury of "cutting corners" where their patients are concerned. If they do, their patients’ health may be compromised. An overt illness may be treated while underlying alcohol problems avoid diagnosis. The distinctions between alcohol abuse and alcohol dependence may be overlooked. Without intervention, problem drinking may develop into dependence. In an effort to identify for clinicians an effective and short screening instrument for alcohol-use disorders, a study in the November issue of Alcoholism: Clinical & Experimental Research (ACER) compares the performance of two short screening instruments.

The Rapid Alcohol Problems Screen (RAPS) is a five-item instrument, derived from other screens, that is designed to maximize sensitivity while maintaining good specificity. The RAPS4, a further refinement of the RAPS, asks if an individual felt guilt after their drinking (Remorse), could not remember things said or did after drinking (Amnesia), failed to do what was normally expected after drinking (Perform), or had a morning drink (Starter). The CAGE questionnaire is a short screening instrument commonly used in the clinical setting that asks if an individual has thought about Cutting down on their drinking, become Annoyed by criticism of their drinking, felt Guilty about their drinking, or had a morning drink as an ‘Eye opener.’ The ACER study compares performance of the RAPS4 and CAGE against the World Health Organization’s (WHO) International Classification of Disease (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV) criteria.

"Numerous screening instruments exist for alcohol-use disorders, explained Cheryl J. Cherpitel, a senior scientist with the Alcohol Research Group and author of the study. "Their usefulness may be limited to certain populations, however, and for identifying alcohol dependence rather than harmful drinking. Most brief screening instruments, for example, have been developed and tested in white male populations. Conversely, little research has been done on how well these instruments work for women or among ethnic minorities in the U.S. Since the RAPS4 was developed from a number of instruments tested in hospital emergency rooms, and performed better in that population – for the total population and by gender and ethnicity – than any of the instruments from which it was developed, it seemed important to test its performance in clinical populations as well as in the general population. The RAPS4 was compared to CAGE in this study because CAGE is the shortest and most widely used brief screening instruments by clinicians."

Researchers analyzed data from the Alcohol Research Group’s 2000 National Alcohol Survey, which were gathered from 7,612 interviews with individuals from the U.S. general population, aged 18 years and older, in 50 states and the District of Columbia.

In general, the RAPS4 outperformed CAGE among the population examined. When two quantity-frequency (QF) questions (drinking five or more drinks on an occasion and drinking as often as once a month) were added to the RAPS4, the RAPS4-QF performed significantly better for alcohol abuse, and outperformed CAGE across all gender, ethnic, and service-utilization groups. The RAPS4-QF also appeared to be most sensitive for alcohol abuse among both males and females reporting emergency-room (ER) use.

Both Cherpitel and Robert Woolard, chair of Brown Medical School’s section of emergency medicine, noted the importance of distinguishing between "alcohol dependence" and "alcohol abuse."

"Patients with mild alcohol problems [such as] harmful drinking will respond to a doctor’s advice or brief counseling session(s)," said Woolard. "They do not require long-term therapy as is often needed by patients with alcohol dependence. By intervening early when or before negative consequences arise from drinking, the poor outcomes associated with dependence, as well as progression of alcohol abuse to dependence, can be avoided."

"Given the findings reported in this article," said Cherpitel, "and previous findings from ER studies, I think the RAPS4 and RAPS4-QF hold a great deal of promise for use in brief screening for alcohol dependence and harmful drinking, respectively, for both men and women and across ethnic groups in both clinical populations – ERs, primary care clinics, other clinical settings – and in the general or non-clinical population. For the average [person, this] means that a few questions can help the doctor or nurse determine who may have a drinking problem which could be helped."

"Busy clinicians need reliable and short screening tests," concurred Woolard. "[But] the greatest utility of Dr. Cherpitel’s work will be the more universal adoption of alcohol screening by clinicians using questionnaires such as RAPS4-QF. Hopefully universal screening in general health surveys, primary care offices and emergency departments will become the norm." Woolard added that he hoped to see future testing of RAPS4-QF by clinicians, and a progression from screening to treatment. "Although it seems obvious and trivial," he said, "demonstrating the impact of the clinical introduction of RAPS4-QF when used by working clinicians would help translate Dr. Cherpitel’s valuable research findings into practice."

Cherpitel will in fact be analyzing the performance of the RAPS4 and RAPS4-QF in ER samples obtained from 12 countries associated with the WHO Multi-Site Collaborative Study of Alcohol and Injury. She calls this "a wonderful opportunity to test the sensitivity and specificity of the instrument from a cross-cultural perspective, [with] implications for its use in other cultures and other countries where resources have not been available for such instrument development."

Funding for this Addiction Science Made Easy project is provided by the Addiction Technology Transfer Center National Office, under the cooperative agreement from the Center for Substance Abuse Treatment of SAMHSA.

Articles were written based on the following published research:

Cherpitel, C.J. (November 2002). Screening for alcohol problems in the U.S. general population: Comparison of the CAGE, RAPS4 and RAPS4-QF by gender, ethnicity, and services utilization. Alcoholism: Clinical & Experimental Research, 26(11), 1686-1691.