population

TABLE 2.-Descriptive information on a variety of screening measures (continued)

Measure

Age or target

ing measure based on the goals and setting unique to a particular screening endeavor. While reemphasizing that point, it nevertheless may be useful to close with some general suggestions regarding screening for alcohol problems. These closing points (see also Allen et al. in press and Maisto et al. in press) are applicable generally to screening but have particular relevance to primary health care settings, where screening for alcohol problems is becoming more frequent.

First, the MAST, one of its derivatives (such as the BMAST or SMAST), the CAGE, and the Alcohol Use Disorders Identification Test can be recommended generally for use with adults. The final choice among these, or between one of these measures and the others listed in table 2, will be dictated by project-specific needs, such as the setting or the population involved. For example, the CAGE may perform better than the MAST among elderly primary health care clients. Another exception may be the TWEAK or T-ACE, which may be particularly applicable in screening women seen in obstetric/gynecologic clinics and other primary care settings. Several other measures, such as the NET, reveal considerable potential as primary health care screening instruments, but more research on them is needed.

Second, fewer options are available specifically for use with adolescents, especially in terms of very brief assessments. Although the CAGE has been proposed for use with adolescents over age 16, it was not developed specifically for use with adolescents. The scales that fall into the category of adolescentspecific (Adolescent Alcohol Involvement Scale, Adolescent Drinking Index, Perceived Benefit of Drinking Scale, Personal Experience Screening Questionnaire, Problem Oriented Screening Instrument for Teenagers, Rutgers Alcohol Problem Index) range in length from 14 to 139 items. If brevity is not a major concern, the Problem Oriented Screening Instrument for Teenagers (available in English and Spanish versions)

includes 10 scales reflecting problem areas in addition to drinking and the potential need for intervention.

Third, screening projects should consider the concomitant use of laboratory tests where available, particularly in health care settings where such tests are routinely performed. Positive results on biochemical tests (e.g., GGT or MCV) may enhance the credibility of self-report screening results when presented to clients.

Fourth, the majority of available screening measures can be administered by clinical or administrative staff with a minimal degree of training. Clerical staff in clinics often have performed the administrative logistics. Further, many of the scales can be adapted for administration in a computerized format.

Finally, any screening endeavor requires responsive procedures for feedback to the individuals screened and appropriate referrals for further evaluation and assessment. The establishment of such procedures is a necessary component of the screening process that needs to be in place prior to the actual testing of individuals.

Future Directions and Needs

A great deal has been accomplished in the area of screening for alcohol problems. Indeed, whatever one's particular needs for a screening tool, several helpful measures are generally available. Further, the choices typically include measures that are brief and easy to administer and interpret.

Despite the many advances in screening, several areas warrant more investigation. Attention to these issues will further advance efforts to efficiently and effectively screen persons for alcohol problems.

One important topic concerns the use of

psychometrically sound criteria that are consistent with what a given screening instrument was designed to measure. Researchers developing screening measures and persons evaluating measures for potential use will want to be certain that the criterion selected is pertinent to their needs. For example, a DSM-IV diagnosis of an alcohol-related disorder derived from a standardized interview likely would provide a reliable criterion but may not be sensitive to heavy drinking itself, a more common problem in health care settings. Taken together, it would appear that more general use of psychometrically sound criteria chosen to reflect screening goals, setting, and population characteristics would advance knowledge about and practice of screening for alcohol problems.

Future research also is needed on the use of screening measures with specific populations, such as adolescents, women, and diverse ethnic groups. A representative example of a new measure is the Research Institute on Addictions Self-Inventory (RIASI), a screening tool designed to briefly but accurately determine which drunk-driving offenders need to be referred for diagnostic evaluation. The screening test, which can be completed and scored in 15 minutes, correctly identifies more than 80 percent of persons addicted to alcohol or other drugs. The RIASI was developed specifically for the New York State Drinking Driver Programs and reflects a careful and empirical development of a screening device for use with a particular population.1

Another area warranting more attention is screening that indicates the extent of alcohol problems as opposed to the more traditional positive or negative screening outcome. One analytic approach that can be useful in this regard is the development of receiver operating curves (e.g., Grant et al.

1 Additional information on the RIASI can be obtained from Thomas H. Nochajski, Ph.D., or Brenda A. Miller, Ph.D., at the Research Institute on Addictions, 1021 Main Street, Buffalo, New York 14203.

1988). Advances in this area will provide greater flexibility in the use of screening measures and in some cases may facilitate subsequent referrals as a function of severity of drinking problems.

Finally, clinical researchers may productively pursue the simultaneous use of multiple screening strategies. As an example, it will be of interest to determine whether the sensitivity or specificity of a particular measure is increased when used in conjunction with another screening strategy, such as the results of a standard blood chemistry profile. What is lost in the brevity and simplicity of a single self-report measure might be offset by greater screening efficiency. As always, final instrument selection would depend on the goals, setting, and resources available.

REFERENCES

Allen, J.P. The interrelationship of alcoholism assessment and treatment. Alcohol Health Res World 15:178-185, 1991.

Allen, J.P.; Maisto, S.A.; and Connors, G.J. Selfreport screens for alcohol problems in primary health care. Arch Int Med, in press. Babor, T.F.; Stephens, R.S.; and Marlatt, G.A. Verbal report methods in clinical research on alcoholism: Response bias and its minimization. J Stud Alcohol 48:410-424, 1987. Feinstein, A.R. Clinical Epidemiology: The Architecture of Clinical Research. Philadelphia: W.B. Saunders, 1985.

Grant, B.F.; Hasin, D.S.; and Harford, T.C. Screening for current drug use disorders in alcoholics: An application of receiver operating characteristic analysis. Drug Alcohol Depend 21:113-125, 1988.

Kristenson, H., and Trell, E. Indicators of alcohol consumption: Comparisons between a questionnaire (Mm-MAST), interviews and serum gamma-glutamyltransferase (GGT) in a health survey of middle-aged males. Br J Addict 77:297-304, 1982.

Leigh, G., and Skinner, H.A. Physiological assessment. In: Donovan, D.M., and Marlatt, G.A., eds. Assessment of Addictive Behaviors. New York: Guilford Press, 1988. pp. 112-136. Maisto, S.A.; Connors, G.J.; and Allen, J.P. Contrasting self-report screens for alcohol problems: A review. Alcohol Clin Exp Res, in press. Maisto, S.A.; McKay, J.R.; and Connors, G.J. Selfreport issues in substance abuse: State of the