A new study published in the Journal of Pediatrics has found that asking about alcohol use frequency may provide primary care practitioners with an effective and feasible method to efficiently identify drinking problems among adolescent patients. The study also found that the age-specific alcohol frequency thresholds recommended by the NIAAA provide acceptable screening results for alcohol use disorder.
Alcohol is the most widely used and abused drug among adolescents living in the United States, especially in rural areas. Alcohol use is associated with a wide range of harmful effects such as acute injuries, trauma, violence and the development of several chronic diseases, and is one of the leading causes of disease and disability.
Considering the relatively high prevalence of harmful effects related to alcohol use among youth, routine screening for underage drinking is often recommended in clinical practice. However, the majority of adolescents visiting primary care practitioners are not provided alcohol screening, with primary care providers stating obstacles such as insufficient training and time constraints. Given higher rates of alcohol use among youth living in rural areas, approaches are needed in rural settings to facilitate screening to efficiently identify adolescents who have problems related to alcohol. Brief screening tools and advances in computer-administered self-assessment techniques may combine to provide primary care practitioners effective and feasible methods to improve their efforts to identify underage drinking in their adolescent patients.
Patterns in the use of alcohol change across the development of adolescents. Likewise, benchmarks for average ages of onset for drinking provide some guidelines in terms of the development of alcohol use behaviour, and suggest the potential use of age-based alcohol screening thresholds. Among teenagers, frequency of alcohol use has been shown in studies to be highly associated with alcohol use disorder. Frequency of alcohol use has been adopted as an item to screen adolescents with alcohol use disorder by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide (NIAAA Youth Guide). Alcohol use disorder is a pattern of alcohol use that includes problems with controlling drinking, having a preoccupation with alcohol drinking, having to drink more to get the same effect, continuing to drink alcohol even when it causes problems, and having withdrawal symptoms when drinking is suddenly decreased or stopped.
In a study recently published in The Journal of Pediatrics, researchers used a computer-administered assessment to describe alcohol use patterns among rural adolescents and to examine the characteristics of alcohol use patterns as screening for alcohol use disorder. Furthermore, they evaluated the NIAAA Youth Guide alcohol frequency screening thresholds when applied to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnostic criteria. The study examined 1193 adolescents who were between the ages of 12 to 20 years old visiting their primary care practitioner in six primary care clinics in the Pennsylvania Wilds between September 1, 2008, and June 3, 2015. Participants were provided a tablet computer that collected self-report data on past year frequency and quantity of alcohol use, and symptoms of alcohol use disorder, as specified in the DSM-5. The main question researchers asked was “how many consecutive days did you consume one or more alcoholic drinks?”
The results confirmed that adolescent alcohol use characteristics were significantly linked to age. Among adolescents between 15and 17 years of age, about 10% matched the criteria for alcohol use disorder in the past year. Adolescents in this age group who reported consuming at least one standard alcoholic drink on 3 or more days in the past year were most at risk for drinking problems. The researchers also found that screening for alcohol use disorder among adolescents ages 15and 17 years with a threshold of 3 or more days with alcohol use in the past year produced 44% positive predictive value (PPV), 99% negative predictive value (NPV), 91% sensitivity, and 89% specificity. Put another way, among those who drank at least one drink on 3 or more days in the past year, 44% were found to have alcohol use disorder, and, in those who drank fewer than 3 drinks in the past year, 99% were found to not have alcohol use disorder. 91% sensitivity means that adolescents with alcohol use disorder were likely to be detected for the disorder by the screen, and 89% specificity indicates that those who did not have alcohol use disorder were likely to have a negative result. These results suggest that for adolescents ages 17 years and younger, a threshold of 3 or more days consuming at least 1 standard drink produces screening results that are optimal for DSM-5 alcohol use disorder.
The researchers found that 10% of adolescents between the ages of 18 and 20 who reported 12 or more days drinking (i.e. at least one standard drink is consumed each day) in the past year met the diagnosis criteria for alcohol use disorder. Alcohol use becomes more frequent in adolescents between the ages of 18 and 20 and usually occurs without alcohol use disorder. This is reflected by reduced specificity (75% of those who did not have alcohol use disorder had a negative result) and lower PPV (31% of those who reported drinking at this level had alcohol use disorder) for frequency thresholds among this age group. These findings indicate that for adolescents ages 18 and 20, a screening threshold of 12 or more drinking days in the past year produces acceptable screening results for alcohol use disorder as specified in DSM-5.
Furthermore, researchers examined the alcohol use frequency screening thresholds recommended in the NIAAA Youth Guide, which uses age-specific alcohol frequency thresholds to identify levels of alcohol use disorder risk by age. “Moderate risk” is defined as 1 or more drinking days in the past year for ages 12 to 15; 3 or more days per year for ages 16 and 17; and 12 or more days per year for 18 year olds. “Highest risk” is defined as 3 or more days per year for youth ages 12 and 15; 12 or more days for 16 year olds; 24 or more days for 17 year olds; and 52 or more days for 18 year olds. Specifically, when applied to participants of the same age range (i.e. ages 12 to 18 years), the NIAAA Moderate Risk thresholds produced acceptable sensitivity (85%) and specificity (87%) for identifying those likely to have one or more symptoms of alcohol use disorder (as specified in the DSM-5). Likewise, the NIAAA5 Highest Risk thresholds showed acceptable sensitivity (91%) and specificity (93%) as a screen for symptoms of severe alcohol use disorder. As a result, both sets of NIAAA guidelines were found to be effective screens and further support the use of alcohol use frequency as screening for alcohol use disorder.
The overall findings confirm that alcohol use frequency shows acceptable validity and reliability as a screen for DSM-5 alcohol use disorder among rural primary care adolescents. When adolescents are asked to report their alcohol use in a primary care setting, computer-administered assessment could facilitate routine alcohol screening. An alcohol use frequency screen followed by an alcohol use disorder evaluation among those who screen positive would provide a brief, simple, and cost-effective clinical assessment method. This threshold is very efficient in identifying adolescents who do not need the further alcohol use disorder assessment, but less efficient in the identification of those who have alcohol use disorder. However, since the following alcohol use disorder assessment is a low-cost and low-risk diagnostic test, the researchers interpret the overall result to be acceptable. Using this reasoning, the thresholds recommended by the NIAA, as well as the optimal thresholds found in this study, produced acceptable screening results for alcohol use disorder.
Written By: Nigar Celep, BASc