Session 2.


Identifying ED Patients with Alcohol Problems


Robert Woolard, MD 

Many patients in the emergency department (ED) have alcohol problems, and they can be identified.1

 Research on techniques used to 

identify these patients has been conducted, but several areas of interest 

should be addressed by further research. We need to further examine 

and refine alcohol-screening questionnaires in the ED. We need to 

determine the sequence and combination of questions and tests that 

constitute the best screening process. We need to study barriers to 

screening, identify factors that promote screening implementation, and 

demonstrate the impact of a screening program in the ED. The final aim 

of screening must be improved outcomes through referral and counseling. Identification is only the first step in a process of care. 

Alcohol problems defined 

Alcohol problems designate a spectrum from risk behavior to illness, 

and from problematic consumption to alcohol use disorder. We must 

be careful when interpreting the results of studies, and in our own 

design of screening procedures, that we are clear about the endpoints 

we are measuring. Clinicians in the ED are interested in screening for 

several alcohol endpoints. Acute intoxication is of concern to emergency 

physicians. Intoxication in a driver would certainly be considered an 

“alcohol problem.” The blood or breath alcohol concentration (BAC), 

coupled with our clinical observations, may help us identify intoxication. Most alcohol screening tests identify patients with alcohol use 

disorders or problematic consumption of alcohol. The American 

Psychiatric Association in DSM III-R, IV2

 and the World Health 

Organization (WHO) in the 9th and 10th International Classification of 

Diseases (ICD-9, -10) have rigorously defined alcohol abuse and alcohol 

dependence.

3 These definitions largely agree for dependence, but not for 

abuse. DSM includes social and legal consequences of abuse and ICD-10 

has only medical and psychological consequences. Fewer cases of alcohol 

abuse meet the ICD-10 definition. In general, an alcohol use disorder is 

present when an aspect of the patient’s function has been compromised 

Identifying Patients with Alcohol Problems 51 
by alcohol. Before function is compromised, problematic consumption 

occurs. Much of the emphasis of screening has shifted toward identifying patients with high alcohol consumption before disease develops. 

WHO defines hazardous drinking as 4 or more drinks/day for men and 

2 or more drinks/day for women. The National Institute on Alcohol 

Abuse and Alcoholism (NIAAA) defines at-risk drinking as consumption of more than 14 drinks/week or more than 4 drinks/occasion for 

men ages 18 to 65. For women of all ages and men older than age 65, 

more than 7 drinks/week or more than 3 drinks/occasion is considered 

at risk. Binge drinking alone is also of concern and has been variably 

defined as more than 3, 4, 5, or 6 drinks on an occasion.4 

Characteristics of an ideal ED screening test or sequence 

of tests 

An ideal screening test would be accurate, practical, and motivational. 

The accuracy of a test can be measured in several ways. For a screening 

test, high sensitivity is the most desirable parameter. High sensitivity 

ensures that most of the patients with problems will be detected. High 

specificity is also desirable to help ensure that positive tests represent 

real problems. There is a trade off between sensitivity and specificity 

defined by the receiver operator curve. The area under the operator 

curve best reflects the performance of a test; the larger the area the better 

the test. Each point on the curve represents a potential “cut point.” A cut 

point with a high sensitivity and specificity should be manifest in an 

ideal test. 

Theoretically, an ideal test should remain accurate throughout the 

alcohol use spectrum. However, real tests don’t perform uniformly 

across a spectrum. For example, if we’re interested in identifying patients 

with binge drinking, we can define binge drinking as 3, 4, 5, or 6 drinks 

on an occasion. Screening tests designed for patients with more severe 

problems (6 drinks) will be less sensitive at identifying patients with less 

severe problems (3 drinks). 

An ideal test would perform uniformly in all populations and subgroups. However, when we screen populations with high case rates 

(trauma admissions, 63%),5

 a highly sensitive test with moderate specificity performs well. The same test used to screen a population with low 

case rates (pregnant clinic patients, 7%)6

 does not perform as well. In 

this population, a test with higher specificity may be needed to avoid 

52 Alcohol Problems Among Emergency Department Patients 
too many false positives. A test that is used to screen a diverse population 

(such as ED patients) will perform better in some subgroups than others 

based of the different case rates among subgroups. 

An ideal test should remain accurate in the presence of common ED 

problems, such as stress, injury, acute illness, intoxication, other drug 

use, depression, and anxiety disorders. Many of the screening tests were 

developed outside the ED. Fortunately, many have been applied to ED 

populations. Hence, their performance has been demonstrated in the 

presence of some of these distracting factors. An ideal test should also 

remain accurate with differences in gender, age, race, ethnicity, or 

language. Some variation in test performance among demographic 

groups has been demonstrated in studies of screening tests in the ED.

7,8 

An ideal test in the ED would address both current and lifetime alcohol 

problems. Current use would more likely prompt referral or counseling, 

but past use predicts poor outcome from medical problems such as 

injury.

9 

In research trials, the impracticality of a screening test may not be 

evident. Research staff do not have to contend with adding a screening 

test to an already lengthy list of clinical care duties. In clinical practice, 

several practical issues will make all the difference to successful implementation. The ease of use of a screening test will determine its success. 

Staff with any level of prior health training and little additional training 

should be able to administer an ideal test. Results should be immediately 

available and easy to interpret. The test should be acceptable to regulators, payers, ED staff, and ED patients. 

Several factors may interfere with implementation. For example, 

patients may find certain questions offensive, or they may not be willing 

to have blood drawn or submit to breathalyzers. Clinical staff may be 

uncomfortable asking some types of questions. Regulators may restrict 

access to records based on answers to certain questions and add burdens 

to hospital record-keepers. Payers may pay for some tests and not others. 

These and other factors may reduce the effectiveness of a screening 

procedure that has been proven effective in research trials. 

Most experts agree that an ideal ED test is brief (1 to 2 minutes). 

Most of the quest to develop efficient ED screening has emphasized 

brevity. However, a longer test could be self-administered. An ideal 

screening test should not interfere with the routine sequence of medical 

history, physical examination, and laboratory testing. The test should be 

Identifying Patients with Alcohol Problems 53 
confidential since there may be legal, financial, or social consequences 

to screening positive. Finally, the ideal test should actually motivate the 

patient to further assessment, counseling, or referral as needed. 

Currently available screening tests 

Based on current evidence, screening should be undertaken using one 

or a combination of structured questionnaires.10 Screening undertaken 

using clinical impression or biochemical tests is not as accurate or as 

sensitive as structured questionnaires for identifying alcohol use disorders or problematic consumption.7

 Of course, BAC can help identify 

acute intoxication. The alcohol concentration can be determined by 

saliva testing, breath analysis, or blood test.11,12 

Clinical impression 

Clinicians often use their general impression to help with diagnosis, but 

clinical impressions concerning alcohol problems can be inaccurate. 

Trained practitioners counseling alcoholics could identify only 50% of 

acutely intoxicated patients.13 Primary care physicians and emergency 

physicians identified fewer than 50% of patients with alcohol problems. 

Unfortunately, the majority of physicians (54%) screen only those 

patients they suspect based on their clinical impressions.14–16 Stereotypic 

profiling may be the consequence of screening only suspected patients. 

Gentilello reported that in a trauma center ED, staff suspected alcoholism in 26% of patients who screened negative on structured questionnaires. These patients were more likely to be young, male, disheveled, 

uninsured, and low income.17 Of course, some ED patients may spontaneously volunteer information about drinking. Cherpitel reported that 

patient self-report of drinking prior to arrival had a sensitivity of 29% 

for alcohol problems in the ED.

7 

Structured questionnaires 

Self-report may be enhanced when specific alcohol questions are asked. 

Cyr reported that a single question in a primary care setting—“Have you 

ever had a drinking problem?”—had a high sensitivity (40% to 70%).18 

Subsequent reports from other institutions did not replicate the high 

sensitivity of this single question.

19–23 Cherpitel evaluated single question 

screens in the ED and found them to be less sensitive than structured 

questionnaires.7 

54 Alcohol Problems Among Emergency Department Patients 
Most existing screens were developed for primary care settings to 

detect alcohol use disorders. The CAGE was developed in 1968 as a 

brief screening tool for primary care providers to detect alcohol abuse 

and dependence. CAGE is a mnemonic from four questions, Cut down, 

Annoyed, Guilty, and Eye opener. The questions address problems over 

the patient’s lifetime. CAGE takes 1 to 2 minutes to administer.

24,25 

The MAST (Michigan Alcohol-Screening Test), developed in 1971 

as a screen for alcohol abuse and dependence, has 24 yes/no questions. 

MAST has been self-administered and used in a computer format. It 

addresses problems over the patient’s lifetime. MAST requires 

20 minutes to administer. A shortened version of the MAST exists, a 

10-question Brief (B) MAST. BMAST takes 5 to 12 minutes to administer and performs nearly as well as the longer version.26–28 

SAAST (Self-Administered Alcoholism Screening Test) was developed 

in 1972 to screen for alcohol abuse and dependence. It has 35 yes/no 

questions. While lengthy, the SAAST has the advantage of being selfadministered, and it has also been administered in a computerized 

format. It addresses problems over the patient’s lifetime. A shortened, 

9-item version, the Brief SAAST, takes the patient 5 to 10 minutes to 

complete.

29,30 

More recently, screens have been developed to detect at-risk drinkers. 

WHO developed the AUDIT (Alcohol Use Disorder Identification Test) 

in 1992 as a brief screening tool to detect at-risk drinking in addition to 

alcohol abuse and dependence. AUDIT has 10 questions. It assesses 

problems experienced within the last three months and over the patient’s 

lifetime. AUDIT takes 4 to 8 minutes to administer.

31,32 

Several screens have been developed for pregnant women. Concern 

about even lower levels of alcohol consumption in this group has 

prompted development of the screens TWEAK, T-ACE, and NET. 

TWEAK screens for alcohol abuse and dependence. It has five questions, 

addresses problems over the patient’s lifetime, and takes 3 to 5 minutes 

to administer.

33 T-ACE also screens for alcohol abuse and dependence. 

T-ACE has three of the four CAGE questions and replaces the guilt 

question with tolerance question. T-ACE addresses problems over the 

patient’s lifetime and takes 1 to 2 minutes to administer.

34 NET was 

developed to screen pregnant patients for at-risk drinking, alcohol 

abuse, and dependence. It is a three-question screen that takes about 

1 minute.33 

Identifying Patients with Alcohol Problems 55 
One screen has been developed for emergency department use, the 

Rapid Alcohol Assessment Screen (RAPS4). Cherpitel screened an ED 

population with questions from CAGE, BMAST, AUDIT, and TWEAK. 

She created RAPS4 by combining the four highest-yield questions from 

those screens, which covered feeling guilty after drinking, blackouts, 

failing to do what is normally expected after drinking, and morning 

drinking. However, this new instrument has not been studied when 

administered as a stand-alone test.35 

In addition to these questionnaires, NIAAA suggests that all primary 

care physicians ask an opening question—“Do you drink alcohol?”— 

followed by three questions about alcohol consumption and then the 

CAGE. This sequence was not explicitly designed or studied as a “screening test.” D’Onofrio and others have recommended using the NIAAA 

approach in the ED.

10 

Studies of screening tests 

Cherpitel conducted two studies comparing multiple screening tests in 

the ED. In the first study, TWEAK and AUDIT were most sensitive, 

identifying 84% and 81% of patients, respectively, with an ICD-10 

diagnosis of alcohol dependence.

7

 In the second study, RAPS and 

AUDIT were more sensitive than TWEAK and CAGE, identifying 79% 

and 78% compared with 72% and 71%, respectively, of patients with an 

ICD-10 or DSM-IV diagnosis of alcohol dependence, harmful drinking, 

or abuse.5,36 

Soderstrom has compared multiple screening tests in a trauma center. 

He reported that CAGE performed best, with a sensitivity of 84%, for a 

DSM-IV diagnosis of alcohol dependence.

37 Fiellin reviewed 38 studies 

of screening for alcohol use disorder in the primary care setting. For 

at-risk, hazardous, or harmful drinking, AUDIT was found most effective with sensitivities of 51% to 97%. For alcohol abuse or dependence, 

CAGE was found most effective with sensitivities of 43% to 94%. As 

expected, CAGE and AUDIT performed best within the spectrum of 

alcohol use they were developed to explore.

38 

Screening biases 

Cherpitel analyzed variability of test performance in subgroups of ED 

patients.39 In her first ED study, CAGE, BMAST, AUDIT, and TWEAK 

were less sensitive among females, whites, and non-injured patients. In 

56 Alcohol Problems Among Emergency Department Patients 
her second ED study with Hispanic patients, CAGE, BMAST, AUDIT, 

TWEAK, and RAPS were less sensitive in females, patients with less 

acculturation, and non-dependent drinkers.

36 Lowering the cut point on 

these screening instruments improved sensitivity without loss of specificity among females. Using lower cut points for females may maximize 

screening test performance.

40 

Bradley reviewed nine studies with data on women’s responses to 

screening mainly in primary care settings. CAGE, AUDIT, and TWEAK 

were the best tests for alcohol dependence among women. Their 

reported sensitivities were 66% to 92%. All three screens performed 

better among black women than among white women. TWEAK performed better than CAGE or AUDIT among white women. CAGE and 

AUDIT had low sensitivities (59% and 48% respectively) for alcohol 

dependence among white women. We must be careful not to employ 

screening techniques that do not address important subgroups.41 

Evidence of such low sensitivity in an important subgroup may 

necessitate use of multiple screens tailored to subgroups. In addition to 

women, other subgroups such as adolescents, older adults, pregnant 

women, psychiatric patients, and Spanish speakers may need screening 

with modified or unique tests. Standard screens may not perform as well 

in these patient subgroups that may represent a considerable part of the 

ED population. Adjustment of cut points or use of alternative screening 

tests may be necessary for these subgroups. 

Alcohol concentration 

Many injured ED patients are screened with a BAC, which can help 

identify intoxication. The presence of alcohol may not always indicate an 

alcohol problem. While a very high BAC in an unimpaired patient can 

be a specific screen for dependence,

42 BAC is an insensitive screen for an 

alcohol use disorder. One study found that only one-third of intoxicated 

drivers had an alcohol use disorder.

43 In an ED study, BAC was a poor 

screen for alcohol abuse or dependence with a sensitivity of 20%, less 

sensitive than self-reported drinking.

7

 In another ED study, a saliva 

alcohol level equivalent to a BAC greater than 0.10 g/dl in an injured 

patient identified harmful drinkers (AUDIT >8) with a sensitivity of 

65%.44 In one trauma center, BAC had a sensitivity of 63% for an alcohol 

disorder.

5

 Other biochemical markers such as mean corpuscular volume, 

platelet count, liver enzymes, gamma-glutamyltransferase (GGT), 

Identifying Patients with Alcohol Problems 57 
aspartate aminotransferase (AST), alanine aminotransferase (ALT), and 

carbohydrate deficient transferrin (CDT) perform poorly with sensitivities of 13% to 67% for alcohol use disorders or problematic consumption.

45–50 Biochemical tests other than BAC may have use in settings 

other than an ED, but they offer little as screening tests for ED patients. 

Research questions: improving existing screening 

questionnaires 

We still need to find the most accurate test for ED use. This may be 

RAPS4, which is designed for the ED, but it needs further direct testing. 

Many tests would be improved by wording questions to address current 

problems (the past year or three months) rather than lifetime problems. 

Screening with embedded questions and indirect questions may also 

improve self-report among adolescents and other groups.20,51–53 These 

approaches need further testing in the ED. 

The most practical test may be the shortest, the three-question NET. 

Further sequencing of questions within questionnaires may also improve efficiency.

35 If one question answered “yes” yields a positive test 

score, asking that one first and stopping as soon as the score is positive 

would be the most efficient approach. Cherpitel has analyzed the sensitivity of each of the RAPS4 questions and sequenced them from most to 

least sensitive for most efficient use.35 

Minimizing question sets for interviews will result in obtaining less 

information. Computer-administered or self-administered screens may 

address this issue by allowing patients to spend more time completing 

in-depth questioning with no additional staff time.54,55 This approach 

promises practical avenues for obtaining more information. A trial of 

screening tests in various formats (e.g., interview, self-administered 

forms, and computer interaction) should be undertaken to compare 

their cost and value in the ED. 

The most motivational screening test is unknown. Drawing blood and 

confronting patients with their blood alcohol levels may actually push 

them away from counseling. Screening questions that reveal the negative 

consequences or link alcohol to current problems may motivate patients 

to seek counseling. Providing immediate feedback may help make the 

transition from screening to counseling with little additional intervention. The motivational aspects of a variety of screens, with and without 

verbal or computer feedback, need to be explored. 

58 Alcohol Problems Among Emergency Department Patients 
Research questions: finding the best approach to screening 

To determine the best of the available screens, a multi-center trial with a 

broad demographic mix and a large number of patients subjected to 

different screens is needed. Further evaluation should be performed of 

lower cut points for TWEAK, CAGE, and AUDIT. The advantage of 

tailored screens or specific questions for subgroups such as women,41 

adolescents,54–59 and elders,60–64 needs to be determined. RAPS4 must be 

further tested as a stand-alone screen in isolation and against other tests. 

A longer, self-administered screen—including one administered by 

computer—should also be tested in the ED. 

To determine the best sequence for screening, the approach recommended by NIAAA for primary care should be compared with other 

sequences. Several trials of variations of the NIAAA approach are 

warranted. Trials should be conducted starting with other or no opening 

questions, using other consumption questions such as those in AUDIT, 

using other screens such as TWEAK rather than CAGE, changing the 

sequence to CAGE or TWEAK followed by consumption questions, and 

checking BAC at the beginning or end of the protocol. 

The best screen should be determined in the context of a screening 

and intervention program. Some questions or screens may lead naturally 

to referral and treatment. Others may not promote referral and treatment. Much of the screening literature is isolated from intervention. 

Future studies need to incorporate evaluation of screening linked to 

intervention protocols. 

Barriers to implementing screening 

In a research protocol in England, nurses were trained to screen all 

emergency patients with CAGE and then provide feedback. Only 20% of 

patients were screened. Of them, 19% had positive CAGE scores; of 

those, only 41% were provided feedback. Even with feedback, only 12% 

accepted follow-up. Of 4,663 patients, only 13 were entered into the trial 

and the trial was abandoned.65,66 

There are multiple barriers to screening. Nurses identified lack of 

resources, inadequate training, stress, poor morale, and no perceived 

value to the intervention. In a survey sponsored by the West Virginia 

Chapter of the American College of Emergency Physicians, a minority 

of emergency physicians reported routine screening and counseling of 

ED patients.67 The authors reported provider attitudes of disinterest, 

Identifying Patients with Alcohol Problems 59 
avoidance, disdain, and pessimism as well as inadequate time, insufficient education, and lack of resources as barriers. Surveys and 

interventions should be undertaken to define and reduce barriers 

to implementing screening in clinical practice. 

Currently, screening is a research tool, not a clinical tool. ED staff does 

not use structured questionnaires for alcohol screening. ED staff has no 

systematic approach to alcohol screening. Staff chooses to screen some 

individuals and not others based on clinical suspicions or partially 

implemented protocols. In general, ED staff screens less often than 

addiction experts recommend. 

Universal screening is appropriate in populations with high case rates. 

EDs have reported high case rates of alcohol problems, especially acute 

intoxication, from 9% to 31%.17,28,46,68–71 Within the ED, there are even 

higher case rates in subgroups. Major trauma, injuries, assaults,72 

depression, and alcohol-related medical problems like gastrointestinal 

bleeding or seizures define even higher risk subgroups. Many experts 

advocate focusing screening on some of the highest-risk groups or 

screening with greater intensity and different tools in these groups. 

Implementing screening in clinical practice 

Any ED staff member could be assigned the screening task. Physician, 

nurse, clerical, social work, or volunteer staff can conduct screening. We 

do not know which staff group will be most effective. Self-administered 

questionnaires, computer screen interactions, or interview techniques 

may be easier to implement. Screening questions can be stand-alone or 

embedded into general health questionnaires or existing registration, 

physician, and nurse documentation. Screening protocols can be 

mandatory or voluntary. The approaches that will be most effective in 

ED practice should be determined by studying the implementation of 

these strategies in actual ED clinical practices. Studies of the translation 

of efficacious research practice into clinical practice is needed most 

since screening instruments have been used by research staff and not 

clinical staff. 

Impact of screening 

ED patient care should be improved by implementing alcohol screening 

programs. A major limit to realizing this improvement is the lack of 

counseling available to address patients’ alcohol problems in most EDs. 

60 Alcohol Problems Among Emergency Department Patients 
Most EDs provide very limited alcohol services. When care is unavailable, screening makes little sense to clinicians. Realizing a gain from 

screening in an ED is entirely dependent upon linking the screening 

program to some form of counseling, onsite or through referral services. 

The impact of screening should be demonstrated in ED environments 

that have treatment available, an adequate volume of alcohol-involved 

patients, and the capacity to undertake clinical trials. Studies in these 

centers should demonstrate the benefits of screening: increased referrals, 

more patients receiving counseling, and better outcomes such as reduction of risk behaviors. 

Summary: research areas of interest concerning screening 

The ideal screen that is accurate, practical, and motivational has not 

been developed. Researchers must continue to analyze the performance 

of structured questionnaires and try computer-based screening tools in 

the ED. The sequence of screening tests needs to be evaluated by studying the NIAAA approach and several alternatives. Screening must move 

from research to clinical practice. Barriers to screening in clinical 

practice must be identified and removed. Studies of implementation of 

screening programs in ED clinical practice should be undertaken. The 

impact of screening on referral and intervention, as well as outcomes 

such as reduced risk behaviors, must be demonstrated. 

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66 Alcohol Problems Among Emergency Department Patients 
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Identifying Patients with Alcohol Problems 67 
Identifying ED Patients with Alcohol Problems: 

Research and Prospects—Discussion 

Cheryl J. Cherpitel, DrPH 

I think Dr. Woolard provided a very thorough overview of the important 

research questions in identifying patients with alcohol problems in the 

ED. Certainly, research on screening tests is important in developing the 

best instrument or the best set of screening items. The application of 

screening in the ED is also an important area of research in relation to 

barriers to screening, the process of implementation, and the impact of 

screening—whether those identified are counseled or are referred for 

counseling, and if referred, whether the referral is accepted. 

As Dr. Woolard pointed out, clinical impression and biochemical tests 

are not as sensitive as structured questionnaires in identifying patients 

with alcohol problems. The utility of clinical impression is presently 

undergoing research by the World Health Organization in a multi-site 

study that is also examining the prevalence of alcohol-related injury in 

ED admissions. This study, which includes sites from China, Africa, 

India, Eastern Europe, Scandinavia, New Zealand, South America, and 

Mexico, will provide baseline data for subsequent studies of screening 

and brief intervention in the ED. The study of clinical impression will 

examine the validity and feasibility of using the ICD-10 Y91 codes in the 

ED, which determine alcohol intoxication of patients by observational 

assessment. A triage nurse or physician will clinically evaluate patients as 

soon as possible after their admission to the ED, and study staff will then 

administer a breathalyzer test as a validity check. A sample of 500 

injured patients arriving at the ED within six hours of injury will be 

selected from each study site. This will include a probability sample of 

300 patients selected on an “around-the-clock” basis, so there will be 

equal representation of all times of the day for all days of the week. An 

additional 200 patients will be selected on weekends only, when there 

will be a greater likelihood that patients will have been drinking. The 

triage nurse or physician will be trained to observe the following signs 

of possible intoxication: smell of alcohol on the breath, slurred speech, 

impairment of motor coordination, impairment of attention and/or 

judgement, euphoria, disturbances in behavioral responses, disturbances 

68 Alcohol Problems Among Emergency Department Patients 
in emotional responses, impaired ability to cooperate, and horizontal 

gaze nystagmus. Based on these signs, the patient’s level of intoxication 

will be assessed as very severe, severe, moderate, mild, not intoxicated, or 

alcohol involved but degree not specified. Although clinical assessment 

of intoxication will not identify problem drinkers who are not intoxicated at the time of the ED visit, it may prove useful in those countries 

with limited resources to detect patients with drinking problems. 

Screening questionnaires probably hold the most promise for accurate 

assessment of problem drinking among ED patients. Important considerations in searching for an “ideal” screen, as Dr. Woolard pointed out, 

include defining the condition or disorder that is being identified 

(whether dependence, abuse, or harmful or hazardous drinking), 

performance of the screening instrument across the spectrum of severity 

of the disorder, the time frame being considered (whether current or 

lifetime), brevity, ease in remembering and using the screening items, 

ability to obtain an immediate diagnosis or identification, and biases of 

screening items in relation to gender and ethnicity. I have found that the 

search for the “best” screen presents some intriguing research questions 

in relation to whether there is an “ideal” set of disorder-specific 

screening questions. Dr. Woolard mentioned the RAPS screen which I 

developed for use in the ED, and which has now been modified to the 

four-item RAPS41

 (Table 1), deleting the question on losing friends 

because of drinking. Sensitivity of the RAPS4 for alcohol dependence 

is as high for females (91%) as for males (94%), and it performs equally 

well across ethnicities (sensitivity of 93% and specificity ranging from 

84% for whites to 89% for Hispanics) (Table 2). Sensitivity of the RAPS4 

is not as good for identifying harmful drinking or abuse, however (also 

true of other screening instruments), with sensitivity for females only 

65%, and 77% across ethnicities. The first item on the RAPS4, having to 

do with feeling guilt or remorse after drinking, identifies the majority of 

those meeting diagnostic criteria for alcohol dependence: 85% of males, 

80% of females, 77% of blacks, 83% of Hispanics, and 84% of whites 

(Table 3). Again, this item is not as sensitive for identifying harmful 

drinking or abuse, ranging in sensitivity from 56% for females to 71% 

for males. The RAPS4 appears to meet several criteria for an “ideal” 

screen. It is simple; no weighting, adding, or scoring of items is required. 

A positive response on any item qualifies as being positive on the RAPS4. 

Identifying Patients with Alcohol Problems 69 
Since the first question identifies more than 80% of those meeting 

criteria for alcohol dependence, the remaining questions may not be 

necessary. It appears to perform equally well across ethnicities and 

performs notably well among females, which many screening instruments do not. 

In the search for the best screen, and to further evaluate the RAPS, I 

was interested in comparing the RAPS items with the best item set from 

the same pool of items optimized in a different sample. We used a 

merged data set from patients in three hospital EDs in Pachuca, Mexico 

(n=537), and Mexican American patients in the ED in the Santa Clara 

Valley Medical Center in San Jose, California (n=332).2

 In this sample, 

the RAPS had a sensitivity of 93% and specificity of 79% (among 

drinkers only). An item selection procedure known as the tree-based 

classification method was used to identify the five best screening items 

from the CAGE, Brief MAST, AUDIT, and TWEAK, based on sensitivity 

for alcohol dependence using ICD-10 and DSM-IV diagnostic criteria. 

The tree-based items—not being able to stop drinking, having friends 

complain about your drinking, feeling a need to cut down on drinking, 

having friends or a doctor suggest cutting down, and failing to do what 

was normally expected because of drinking—had a sensitivity of 98% 

and a specificity of 65%. Only one of the items, failing to do what was 

normally expected, overlapped with the RAPS items. The RAPS items, 

which were selected to optimize sensitivity while maintaining good 

specificity, included two physiological symptoms of dependence, while 

the tree-based model items were selected to maximize sensitivity without regard for specificity, and included only one physiological symptom. 

The differing criteria for item selection relating to sensitivity versus 

specificity may account for the lack of congruence between the two sets 

of items and suggests, not surprisingly, that consequence-of-drinking 

items may provide better sensitivity, while physiological items may 

increase specificity. This is an area of research that may deserve further 

exploration. Of course, we do not know how well the tree-based model 

may work in non-Mexican/Mexican American populations or as a 

stand-alone instrument, and further research is also needed on the RAPS 

as a stand-alone instrument. 

Finally, in relation to the application of screening measures and 

identification of alcohol use disorders in the ED, the United Kingdom 

has led the United States in studies of screening and brief intervention 

70 Alcohol Problems Among Emergency Department Patients 
in primary care, and we may have lessons to learn in application processes as well. One instrument which has been used to some extent in 

the United Kingdom is the Paddington Alcohol Test (PAT).3

 This instrument requires one minute to use and is usually administered by a triage 

nurse who asks the patient what is the most he will drink in any one day 

(eight or more units for men and six or more for women is considered 

positive); if positive, whether he or she drinks at this level more often 

than once a week; and whether the current attendance in the accident 

and emergency department is related to alcohol. If the patient scores 

positive on these items, he or she is referred to the alcohol health worker 

who is based in the hospital. Having such an individual available for 

counseling is probably the key to success of this screening and intervention program. 

In summary, regardless of what we may find as the best screening 

instrument, future research will also need to explore the acceptability of 

the screen for use by ED personnel and the ease of implementation of 

the screen within the scope of usual practice in the ED. 

References 

1. Cherpitel CJ. A brief screening instrument for problem drinking in the 

emergency room: the RAPS4. J Stud Alcohol 2000;61:447–9. 

2. Borges G, Cherpitel CJ. Selection of screening items for alcohol abuse and 

alcohol dependence among Mexicans and Mexican Americans in the emergency 

department. J Stud Alcohol 2001;62(3):277–85. 

3. Smith SGT, Touquet R, Wright S, Das Gupta N. Detection of alcohol misusing 

patients in accident and emergency departments: the Paddington Alcohol Test 

(PAT). J Accid Emerg Med 1996;13:308–12. 

Identifying Patients with Alcohol Problems 71 
Table 1.


The Rapid Alcohol Problems Screen (RAPS4)


1.5 During the last year, have you had a feeling of guilt or remorse 

after drinking? (Remorse) 

2.5 During the last year, has a friend or a family member ever told 

you about things you said or did while you were drinking that 

you could not remember? (Amnesia) 

3.5 During the last year, have you failed to do what was normally 

expected from you because of drinking? (Perform) 

4.5 Do you sometimes take a drink when you first get up in the 

morning? (Starter) 

72 Alcohol Problems Among Emergency Department Patients 
Percent 

Percent 

Table 2.


RAPS4: Sensitivity and Specificity for


Alcohol Dependence (ICD–10 and DSM IV)


in Santa Clara


100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Total Males Females 

87 

80 

92 93 94 91 

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Black Hispanic White/Other 

87 89 

84 

93 93 93 

Sensitivity Specificity 

Identifying Patients with Alcohol Problems 73 
Percent 

Percent 

Table 3.


REMORSE: Sensitivity and Specificity for


Alcohol Dependence in Santa Clara


100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Total Males Females 

84 

80 

88 

83 84 

80 

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Black Hispanic White/Other 

86 86 

82 

77 

83 84 

Sensitivity Specificity 

74 Alcohol Problems Among Emergency Department Patients 
Comment on Dr. Woolard’s Presentation on 

Alcohol Screening in Emergency Rooms 

Richard L. Brown, MD 

Dr. Woolard did a very nice job summarizing some key findings and 

needs regarding alcohol screening research, and I appreciate the information Dr. Cherpitel added. I will highlight some of the points they 

made and add some others. 

Dr. Woolard emphasized the importance of accuracy, brevity, and 

practicality of alcohol screening tools. He appropriately described many 

of the available screening tests, their differential accuracy for different 

population groups, and the need for additional studies of certain groups. 

He pointed out an important concern, that researchers have often used 

different diagnostic interviews in assessing the criterion validity of 

screening tools. This can make it difficult to compare screening tools 

for accuracy. Another concern about most research on the validity of 

alcohol screens is that the screens and diagnostic interviews are usually 

administered by research staff. This methodology may not tell us enough 

about the accuracy of screens under actual clinical conditions. Screens 

may be less accurate when administered by clinicians outside of 

academic settings, because of stigma, shame, and concerns about 

confidentiality, judgment, and impact on clinical decisions and future 

insurability. It would be interesting to compare the results of screens 

administered by those clinicians with diagnostic interviews administered 

confidentially by research staff. 

Dr. Woolard appropriately emphasized the importance of some 

practical issues of implementation. Screening can be administered in 

different ways, such as orally in person, orally over the telephone, in 

writing, by computer, and by telephone menu systems. Screens can be 

administered by various health care professionals. As Dr. Woolard said, 

we do not know what method of administration and which professionals 

can elicit the most accurate information, especially when screening 

results will be made available to clinicians. 

Dr. Woolard suggested that another important criterion of a good 

screening test is its motivational value. Indeed, many randomized 

Identifying Patients with Alcohol Problems 75 
controlled trials of brief interventions have shown significant improvement in control groups, perhaps because the screening and assessment 

procedures foster self-examination. I am not aware of any studies that 

evaluate whether the administration of brief screens, or simple feedback 

on the results of such screens, can elicit changes in drinking. Such 

studies of what might be called super-brief interventions would be 

interesting. 

Questions about whether alcohol screening by itself is motivational 

remind us that the most important test of the utility of gathering clinical 

information is whether such information produces better health outcomes. This is best illustrated in the cancer screening literature. Cancer 

screening techniques are not simply compared against biopsy results. 

Randomized controlled trials are performed to determine whether 

individuals who undergo cancer screening live longer than those who 

do not.1–3 Although good research exists to show that alcohol screening 

and intervention programs do reduce harm, and at least one study 

suggests cost savings, studies showing that alcohol screening prolongs 

lives might help promote policy changes. 

If our goal is to improve health outcomes through alcohol screening, 

and if we therefore wish to optimize alcohol screening, we must consider 

how such screening results will be used. Thus, we get back to the issue 

of an appropriate criterion standard for assessing the accuracy of 

screens. Many studies have used diagnoses of alcohol abuse and dependence as criterion standards. Such studies have undervalued identifying 

individuals who are drinking in a hazardous manner and would be 

responsive to brief interventions. Therefore, screens should certainly be 

targeted at identifying at-risk drinkers in addition to those with DSM-IV 

diagnoses of alcohol abuse and dependence. 

If we continue thinking about how we can optimize alcohol screening 

to improve outcomes, we begin to realize that screening could do more 

than just identify individuals who drink too much. Perhaps quick 

screens could also help predict patients’ responsiveness to different kinds 

and intensities of interventions or referrals. Screens could help indicate, 

for example, whether a more confrontational or motivational approach 

would be more effective. Perhaps screens could also suggest whether the 

patient would respond better to intervenion staff of certain demographic groups, personality attributes, or professional roles. 

76 Alcohol Problems Among Emergency Department Patients 
So far, I have spoken implicitly about the need to conceptualize 

screening and intervention as an integrated process. Another need for 

integration relates to the relationship between alcohol consumption and 

other health risk behaviors. For example, research has shown that many 

alcoholics die of tobacco-related diseases. Alcohol dependence and other 

drug dependence are certainly associated. I have published research on a 

two-item conjoint screen (TICS),4

 which shows nearly 80% sensitivity 

and specificity for alcohol or drug abuse or dependence among primary 

care patients. Alcohol use disorders are interrelated with unsafe sexual 

behaviors, depression, domestic violence (for both perpetrators and 

survivors), child abuse, and motor vehicle crashes, to name a few. 

Clearly, we should be developing and testing multiphasic behavioral 

screening instruments and programs. 

This kind of multiphasic behavioral screening would be especially 

challenging for emergency departments, whose primary stated purpose, 

as we heard earlier, is providing excellent, efficient care for acute concerns. Should emergency departments really take on this preventive 

function? We have already discussed the possibility that visits to emergency departments may be special teachable moments. If this is true, 

then these opportunities certainly should not be lost. More importantly, 

in a nation where many individuals’ only contact with the health care 

system is the emergency department, emergency departments must 

provide this preventive care. 

The next question is, then, how can emergency departments possibly 

provide alcohol screening, or multiphasic behavioral screening, and the 

subsequent interventions? I believe that the answer will be a creative 

combination of technology and human resources. Interactive computer 

programs could identify at-risk and problem drinkers, perform brief 

interventions, and offer referrals. Computers could interact with 

patients in different languages. They could depict helping professionals 

of various demographic and cultural groups. They could administer the 

screening test known to be most accurate for the patient’s population 

group. Emergency department staff could simply provide reinforcement, answer further questions, and assist with referrals. Follow-up 

care could occur in person or by telephone or e-mail. It is not a great 

stretch to envision a community-based or managed care–based 

behavioral risk management system in which emergency departments 

Identifying Patients with Alcohol Problems 77 
are just one of many venues for systematized, computer-based screening, 

and individuals who need more help are referred to more centralized 

referral resources. Examples of these systems should be developed and 

evaluated. 

In summary, I would suggest the following research agenda for 

alcohol screening: 

● We need accurate, brief screens for all population groups. 

●	 We need to identify the most effective and efficient ways 

to administer screens, keeping in mind that there may be 

variability across population groups. 

●	 We need screens that have demonstrated accuracy, not just 

as they are administered by researchers, but also as they are 

administered in clinical settings. 

●	 We would like screens that begin to motivate behavior 

change. 

●	 It is already clear that screening followed by intervention can 

reduce harm and perhaps decrease costs. It would be interesting to know whether alcohol screening, like cancer screening, 

can save lives. 

●	 We need screens that will identify at-risk drinkers as well as 

individuals with alcohol abuse or dependence. 

●	 We need to develop and test multiphasic behavioral screens. 

We might start at least with combined alcohol and drug 

screens. 

●	 We need to develop and test technology, and combinations 

of technology and human resources, to perform alcohol 

and other behavioral screening with cultural sensitivity, 

effectiveness, and efficiency. 

It is likely that alcohol screening and subsequent services can be 

provided in ways that do not hinder emergency departments from 

addressing their primary mission of providing acute medical care. 

78 Alcohol Problems Among Emergency Department Patients 
References 

1. Kerlikowske K, Grady D, Rubin SM, et al. Efficacy of screening mammography. 

A meta-analysis. JAMA 1995;273:149–54. 

2. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal 

cancer by screening for fecal occult blood. N Engl J Med 1993;328:1365–71. 

3. Winawer SJ, Flehinger BJ, Schottenfeld D, Miller DG. Screening for colorectal 

cancer with fecal occult blood testing and sigmoidoscopy. J Natl Cancer Inst 

1993;85:1311–8. 

4. Brown RL, Leonard T, Saunders LA, Papasouliotis O. A two-item conjoint 

screen for alcohol and other drug problems. J Am Board Fam Pract 2001;14: 

95–106. 

Identifying Patients with Alcohol Problems 79 
General Discussion 

Elinor Walker noted the breathalyzer is not really predictive for alcohol 

problems, so she asked what “gold standards” are being used to validate 

screening instruments for alcohol problems. 

Cheryl Cherpitel, Richard Brown, and Robert Woolard noted that 

screening instruments are usually validated against criteria for alcohol 

abuse, alcohol dependence, or harmful drinking from the Diagnostic 

and Statistical Manual of Mental Disorders - 4th edition (DSM-IV) or 

the International Statistical Classification of Diseases and Related Health 

Problems, 10th revision (ICD-10). These diagnoses are determined by 

diagnostic interviews that have been developed and validated by a 

variety of sources. In clinical practice, further interviewing after the 

screening often confirms a diagnosis. 

Cherpitel said the “gold standard” for alcohol dependence includes 

physiological symptoms as well as behavioral and psychological 

domains. As the United States continues to gain citizens from other 

parts of the world, it will be more important to determine if these 

domains are valid across cultures. 

Richard Longabaugh commented that the important criterion for 

screening should be the likelihood of harm occurring if the patient’s 

behavior does not change. The same behaviors in different cultures can 

have different consequences, he said, so the practical task is difficult. 

Richard Ries pointed out that diagnostic interviews and criteria are 

artificial gold standards. Neither gathers much information about 

at-risk people, and people can lie as well in structured diagnostic 

interviews as they can on screening instruments. 

Thomas Babor noted that the diagnostic criteria are sometimes as 

questionable as the screening tests themselves. Both are based on a 

clinical model that assumes a patient either has or does not have a condition. That model does not necessarily apply even to physical disorders 

where there is a continuum of severity, never mind behavioral disorders. 

To take advantage of screening tests, he suggested that cut-off points 

along the spectrum will help differentiate between people at the lower 

end of the spectrum, who are at risk, and people at the higher end, who 

80 Alcohol Problems Among Emergency Department Patients 
most likely have a condition. These points can help ED personnel decide 

whether a “teachable moment” will help a patient change his behavior 

or whether a short intervention will not be worthwhile and a referral 

would be more helpful. 

Brown noted that studies show that even many dependent drinkers can 

cut down or quit drinking without help. Therefore, he questioned the 

usefulness of grading the severity of a patient’s problem in order to 

decide who should get an on-site intervention and who should be 

referred for more extensive alcohol treatment. He recommended first 

trying a brief intervention and then referring a patient after that, if 

needed. 

Gordon Smith noted a study that involved a mistaken re-ordering 

of screening questions, which yielded a different prevalence estimate. 

He asked the panel to address the issue of the effect of ordering test 

questions. 

Woolard noted one study showing that if the CAGE is administered 

after the consumption questions, its sensitivity is lower. 

Brown commented that asking quantity and frequency questions first 

often results in patients becoming defensive if the answers are high. 

Then they are not comfortable answering questions about alcoholrelated harm. 

Babor added that the literature does not show that ordering of questions 

has a large degree of influence. Questions about alcohol consumption 

should logically be asked before questions about consequences or 

symptoms. If a patient does not drink alcohol, the other questions are 

not applicable. 

Woolard recommended that future testing of questionnaires should 

be done in conjunction with interventions in order to evaluate which 

combinations of screening instrument and intervention are most 

effective and efficient. 

Alison Moore advocated more research on screening measures for 

identifying alcohol problems among older people because current 

screening measures have not been reliable, and alcohol can interact 

Identifying Patients with Alcohol Problems 81 
with the large number of medications they take. The DSM and ICD 

criteria may be less relevant in this age group. In addition, the legal and 

social consequences of alcohol abuse often used in screening instruments are different for older people. 

Brown responded that pharmacists can be of great help in the issues of 

medication interactions among the elderly. Pharmacists are expected to 

conduct patient education, which can include identifying patients who 

are being prescribed potentially addictive medications or medications 

intended for conditions that are often related to alcohol. 

Woolard noted that lower levels of alcohol consumption can produce 

problems for older adults. Since many questionnaires focus on lifetime 

experience, older persons have a very high likelihood of replying in the 

positive, which may lead to false positives when looking at current 

problems. The ED serves such a broad variety of patients, a computer 

that asks the patient’s age and then produces appropriate questions 

might be the best way to screen. 

Mary Dufour commented that some combinations of over-the-counter 

and prescription medicines that older people may take can lead to 

adverse drug interactions and ED visits. 

Bruce Becker inquired about the chronology of the issues related to 

drinking and the screening questions. He asked the panelists to comment on whether, in terms of the ED, a 1-month, 6-month, or 12-month 

prevalence of drinking behavior would be the most relevant. He also 

asked why Dr. Cherpitel chose the time frame of “in the last year” for the 

Rapid Alcohol Assessment Screen (RAPS), and he wondered whether a 

shorter time frame might be more effective in the acute, ED setting while 

the longer time frame applies to a survey situation. 

Brown responded that any time frame can be relevant. Information 

about current drinking can identify patients with active problems or 

risks, and the past history of dependence can be useful in identifying 

patients who are at risk for a relapse or might develop addictions to 

prescribed medications. 

Cherpitel replied that she had not analyzed data to inform her choice of 

time frame. She noted that in national surveys, respondents are routinely 

82 Alcohol Problems Among Emergency Department Patients 
asked for drinking episodes over their lifetime and in the last 12 months, 

so it seemed like a standard in the field. 

Woolard added that a recent trauma center study used acute intoxication as the criterion for alcohol problems rather than screening questions. Patient outcome was more closely associated with results of the 

screening interview than the presence of acute intoxication. From the 

emergency perspective, a year seems like a long time frame for questions 

about drinking, but at some point, both long- and short-term use of 

alcohol are factors. 

David Fiellin noted that there were tests with good operating characteristics and that 20% of primary care doctors use screening instruments. 

However, he suggested that getting screening to take place in the ED is a 

more important research issue than quantifying performance characteristics of specific screens. 

Woolard agreed that the question of how to implement screening was 

crucial and that some tests may be more acceptable than others. 

Larry Gentilello commented that trying to discover the best screening 

test or the best single question might be too abstract. The best tool 

depends on the projected treatment, the particular type of patient, and 

what a particular hospital can offer. 

Woolard agreed that research on the sequence of test-interventionoutcome is important. However, because so many screens are available, 

projects will also need more information about them to match the right 

one to their local conditions and needs. 

Fred Blow noted that personal digital assistants can increase the efficiency of screening and interventions. They can rapidly segment the 

population so that different screening questions can be asked of patients 

by age, gender, and level of risk. Brief interventions can then be focused 

on the level of risk or the segment of the population. 

Gail D’Onofrio noted that all screening questions do not have to be 

asked of all patients because 40% of the population does not drink. 

She added that information technology can be used to automate 

alcohol screening in the ED. 

Identifying Patients with Alcohol Problems 83 
Phillip Brewer noted that ED staff may be pressed for time, but the 

patient has plenty of time and might welcome the diversion of a 

computerized intervention. He cited the potential efficiency advantages 

of computerized screening. It could automatically generate a document 

for a patient to keep and medical staff to use as a tool for follow-up. 

Different languages can be used, and the ability to read would not be 

required. He recommended that future research should determine if 

computer technology and data information systems could be used to 

screen systematically without hiring more people. 

Woolard agreed, citing activities that used to be labor-intensive and are 

now automated and self-administered, such as withdrawing money from 

the bank or putting gasoline in a car. The same phenomena could occur 

in the ED. Pilot studies have been successful when patients interacted 

with laptops or hand-held computers. 

Ries mentioned that some patients are too intoxicated or too injured to 

be included in studies. He approved of using information technology, 

but said a research agenda should address patients who are not able to 

respond to computers. 

Ronald Maio asked whether the research agenda should include a focus 

on prevention of medical errors and injuries among intoxicated patients. 

Woolard noted that no other clinical medical practice sees such a high 

percentage of acutely intoxicated patients. 

Brown stated that performing an intervention on an intoxicated patient 

is unlikely to have an impact. He described pilot studies that suggest that 

telephone interventions are effective with patients who are screened in 

primary care waiting rooms and wondered whether that kind of intervention could be extended to intoxicated patients once they are sober 

and released from the ED. 

D’Onofrio commented that only about 5% of patients are dependent on 

alcohol. Since intoxicated patients are so disruptive, a vast amount of 

time is spent on them in the ED. She recommended we focus on other 

patients at risk for alcohol problems because brief interventions work 

well with them. Patients with severe problems should get a referral. 

84 Alcohol Problems Among Emergency Department Patients 
Cherpitel noted that the proportion of ED patients who are alcoholdependent varies greatly. In EDs where there is a high rate of dependence, almost everyone would screen positive which could overload 

the referral or intervention system. Specific clientele and resources 

come into play when making decisions, she said. 

Brown suggested that pessimism about interventions for alcohol problems that many health care professionals have may stem from the fact 

that only end-stage dependent patients tend to be recognized. If physicians can experience identifying someone early on and see that they 

can make a difference, then there might be less pessimism. 

Edward Bernstein noted that ED personnel other than nurses and 

physicians can do the screening and interventions. He suggested that 

implementation research can evaluate different approaches. One 

approach could involve a computer kiosk that embeds alcohol questions 

in a general health screen and prints out results with educational 

material. Another approach could use health promotion advocates that 

interact with patients directly. Another approach is to have physicians 

questioning patients about health practices when collecting medical 

history. A triage approach could use a checklist on intake forms. 

Woolard commented that when talking about implementing screening 

in the ED, the question is always, “What staff will do it?” A model that 

is not limited to alcohol, but screens for a wide variety of health issues, 

might have a better chance of funding. 

Linda Degutis said a recent survey of emergency nurses and physicians 

in Connecticut found that they usually ask their patients about alcohol 

consumption or problems, but fewer than 25% used screening tools. 

About 20 years ago, the Yale ED evaluated whether prompts on 

medical records increased compliance with recommended practices. 

Practitioners who received feedback were more likely to comply. She 

recommended applying this concept to alcohol screening. 

Woolard noted that education remains the key. Medical school and 

residency programs should reinforce the CAGE, for instance, and 

embed those questions into existing documentation. 

Identifying Patients with Alcohol Problems 85 
Brown said that medical students and residents often try to ask patients 

about alcohol, but they do not know what questions to ask. With a 

structured approach, they can ask more questions and do more good. 

Patricia Perry wondered whether patients would get a brief intervention 

from the person who did the screening or from someone else. She said 

the answer to that question would change the kind of screening needed. 

Woolard replied that whatever option was chosen, future research on 

screening should focus on screening that is linked to interventions. He 

noted that another option would be to use more sophisticated, less 

labor-intensive general screening, which could be executed through 

computer. 

Becker observed that screening itself can act as an intervention. In one 

smoking study, patients in the control group thought that they were in 

the intervention group, and vice versa. When screening is paired with an 

intervention, how can the intervention effects be separated? 

Woolard added that just the visit to the ED could motivate change. 

Cherpitel agreed that this is an evaluation problem for researchers. 

However, if a patient thinks that the screening is an intervention, then 

there has been an intervention. 

Brown noted that one possibility would be to use a comparison group 

from another ED where this research is not going on. 

Kristen Barry noted that she and her colleagues had been concerned 

about this issue so they randomized patients into either a brief assessment or a more extensive assessment. Length of assessment did not 

produce differences in how many patients reduced their drinking. From 

a clinical standpoint, she said that if screening shows a behavior change 

in the people that are being screened, it is not necessarily a bad outcome, 

even though clinical trials are not helped. 

Peter Rostenberg commented that physicians underestimate the power 

of their advice and their interactions with their patients. Shorter 

screens, he said, are key if they are going to be integrated into the 

history assessment. 

86 Alcohol Problems Among Emergency Department Patients 
Carlo DiClemente wondered if the group was not asking too much of 

screening. The screening is as much for which patients do not require 

further intervention as it is for patients who are identified. Screening 

should be an opportunity to begin a conversation, not an ultimate tool. 

Peter Monti commented that for the most part, the pure and simple 

alcoholic does not exist anymore. Most patients are abusing multiple 

substances, he said, and screens must be developed and linked with 

interventions with this fact in mind. Brief interventions have been 

found to be effective with a number of substance abuse problems, he 

said, including marijuana and nicotine dependence. 

Identifying Patients with Alcohol Problems 87