A two-item screening test for alcohol and other drug problems

Journal of Family Practice, Feb, 1997 by Richard L. Brown, Tom Leonard, Laura A. Saunders, Orestis Papasouliotis

BACKGROUND. Although nonmedical use of illicit and prescription drugs is not uncommon among American adults, the currently recommended screening tests for substance use disorders (SUDs) focus only on alcohol. This study reports on the criterion validity of a two-item conjoint screening (TICS) test for alcohol and other drug abuse or dependence for a primary care sample.

METHODS. A random sample of 434 primary care patients aged 18 to 59 years responded to nine screening items, which emanated from a focus group process. The DSM-III-R criteria for SUDs, as operationalized by the Composite International Diagnostic Interview-Substance Abuse Module, served as the criterion standard.

RESULTS. At least one positive response to the TICS ("In the last year, have you ever drank or used drugs more than you meant to?" and "Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?") discriminated current SUDs with approximately 81 % sensitivity and specificity. The TICS was particularly sensitive to polysubstance use disorders. Respondents with zero positive responses had a 7.4% chance of a current SUD; one positive response, 45.0%; and two positive responses, 75.0%.

CONCLUSIONS. More than 80% of young and middle-aged patients with current alcohol or other drug problems may be recognized by the TICS, which is easily integrated into a clinical interview.

KEY WORDS. Alcoholism; substance abuse; mass screening; drug screening; primary health care. (J Fam Pract 1997;44:151-160)

Previous reports have documented the need for a brief, accurate screening tool for substance use disorders (SUDs) for use in health care settings.[1,2] Most patients provide accurate responses to direct questions regarding nicotine use,[3-5] but direct questions may frequently fail to elicit accurate information on the use of other drugs.[6] Therefore, screening tools are needed particularly for alcohol and other commonly abused drugs besides nicotine.

The screening protocols currently recommended for health care settings focus only on alcohol.[7-10] Screening protocols developed for other drugs are too inaccurate or lengthy to garner widespread use in medical settings.[7,11-15] The need for screening tools that address a wider scope of substance abuse is particularly cogent in light of the proportion of persons who have SUDs involving drugs other than alcohol[16] (Brown, Leonard, Rounds, Papasouliotis. 1996. Unpublished data), the increasing contribution of drug abuse to the spread of the acquired immunodeficiency syndrome (AIDS),[17] and the known effectiveness of many forms of treatment for drug abuse and dependence.[18]

A particular advantage to screening for alcohol disorders is that such disorders, when identified early enough, can respond to relatively inexpensive and nonintrusive brief interventions.[19-21] Studies on the effectiveness of brief interventions for drug abuse are underway. If such interventions do succeed, then a brief screening tool for drug abuse would be a useful way to identify possible candidates for brief interventions.

Brown[22] initially advanced the concept of conjoint screening questions in 1992. A conjoint screening question is defined as a question that inquires simultaneously and in aggregate about experiences with alcohol and other drugs. An example of a two-item conjoint screening (TICS) question, derived from one of the CAGE questions, is "Have you ever felt guilty about your drinking or drug use?" There are at least three reasons to believe that conjoint questions would be preferred over separate questions for various substances[23]:

First, patients who have problems related to multiple substances may more readily respond positively to a conjoint question than to separate questions on individual substances. For example, someone who gets into fights from drinking, suffers exacerbations of asthma due to marijuana smoking, and has frequent absences from work because of cocaine withdrawal might perceive a need to decrease his or her substance use in general more than a need to decrease the use of any particular substance.

Second, patients may be less likely to conceal affirmative responses to conjoint questions than to other questions on the use of particular illicit substances. It is widely understood that patients are often reluctant to inform clinicians about their use of illicit drugs because of stigma, possible legal ramifications, and possible effects on obtaining health and life insurance. Individuals can respond affirmatively to conjoint questions without necessarily indicating that they are using illicit drugs, since their affirmative responses could stem entirely from alcohol use.

Third, conjoint screening questions would allow clinicians to screen for alcohol and drug problems as rapidly as they can screen for alcohol problems. Brevity is important for clinicians because of economic pressures for efficiency and recommendations to conduct many other screening and prevention activities in health care settings.[7]