Am J Drug Alcohol Abuse 1977.4:257-266. Downloaded from informahealthcare.com by McMaster University on 11/03/14. For personal use only.
AM. J. DRUG ALCOHOL ABUSE, 4(2), pp. 257-266 (1977)
The Use of an Alcoholism Screening Test to Identify the Potential for Alcoholism in Persons on Methadone Maintenance AARON COHEN, M.S. WILLIAM McKEEVER, M.S. MURRY COHEN, M.D. BARRY STIMMEL, M.D. Departments of Medicine and Psychiatry Mount Sinai School of Medicine of The City University of New York New York, New York 10029
ABSTRACT Alcoholism has become a problem of increasing prominence in persons enrolled in methadone maintenance programs. Since early identification of the potential problem drinker may result in successful intervention, a method to screen individuals applying for admission to methadone maintenance who have a proclivity toward alcoholism would be of great value. A modified self-administered alcoholism screening test (SAAST), previously confirmed to identify “hidden alcoholics” in a general nonnarcotic-using population, was utilized as a screening device in three groups of narcotiodependent persons on methadone maintenance: 30 individuals who had a known problem with alcoholism, 30 individuals without any history or signs of alcoholism over an extended time period, and 80 persons entering methadone maintenance who initially denied any problems with excessive drinking. The ability of the modified SAAST to separate the alcoholic from the nonalcoholic narcotic addict was mnfiimed (p < 0.001). This test was also found to have considerable predictive value in determining those individuals initially denying a history of excessive alcohol intake who become problem drinkers.
257
COHEN ETAL.
258
Am J Drug Alcohol Abuse 1977.4:257-266. Downloaded from informahealthcare.com by McMaster University on 11/03/14. For personal use only.
Expected Alcoholic Response
+
1.
-
2.
+
3.
+
4.
Do close relatives ever worry or complain about your drinking?
-
5.
Can you stop drinking without a struggle after one or two drinks?
+
6.
-
7.
-
8.
+
9.
Do you ever feel guilty about your drinking? Do friends or relatives think you are a normal drinker? Are you always able to stop drinking when you want to? Have you every attended a meeting of Alcoholics Anonymous (AA) because of your drinking? Do you ever drink before lunch? (19) Have you gotten into physical fights when drinking? Has drinking ever created problems between you and your wife, husband, parent, or near relative? Has your wife, husband, or other family member ever gone to anyone for help about your drinking? Have you ever lost friends because of your drinking? Do you get rowdy when you drink? (11) Have you ever gotten into trouble at work because of your drinking? Have you ever lost a job because of your drinking? Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking? Do you ever drink in the morning? Have you ever felt the need to cut down on your drinking? Have there been times in your adult life when you have found it necessary to completely avoid alcohol? Have you ever been told that you have liver trouble (cirrhosis)? Have you ever had delirium tremens (DT’s)? Have you ever had severe shaking, heard voices, or seen things that weren’t there after heavy drinking? Have you every enjoyed a drink? (1) Have you ever gone to anyone for help about your drinking? Have you ever been in the hospital because of your drinking? Have you ever been told by a doctor to stop drinking?
10.
+ +
11.
+
13.
+
14.
+ + +
16.
+ + +
19.
12.
15.
+ + +
17. 18.
20. 21. 22. 23. 24. 25.
+ + +
26. 27. 28.
Do you enjoy a drink now and then? Do you feel that you are an average drinker? Have you ever awakened in the morning, after some drinking the night before, and found that you could not remember part of the evening?
ALCOHOLISM SCREENING TEST
259
Am J Drug Alcohol Abuse 1977.4:257-266. Downloaded from informahealthcare.com by McMaster University on 11/03/14. For personal use only.
Expected Alcoholic Response
+
29.
Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital?
+ +
30. 31.
Was drinking part of the problem that resulted in that hospitalization?
+
32.
Have you ever been arrested, even for a few hours, because of drunken behavior? How many times?
33.
Have you ever cut down on your drinking by switching to something else? (20)
34. 35.
Have you ever been told that you have a drinking problem? (4)
Have you ever been a patient a t a psychiatric or mental health clinic or gone to any doctor, social worker, or clergyman for help with any emotional problems?
Have you ever been arrested, even for a few hours, because of driving while intoxicated? How many times? Have any of the following relatives ever had problems with alcohol?
36. 31. 38. 39.
Parents Brothers and sisters Husband or wife Children
Fig. 1. Self-administered alcohol screening test (modified from Swenson and Morse IS]). Questions 10, 15, 25, 33, and 34 are validity questions with the number of the similar question indicated in the parenthesis.
The diagnosis of alcoholism, particularly in its early stages, is exceedingly difficult. Not infrequently, through denial on either the part of the patient or therapist, an advanced state of alcoholism is allowed to occur prior to its recognition. The prevalence of alcoholism in patients enrolled in methadone maintenance programs has been well described [l-41. Unfortunately, although these individuals are seen daily by treatment staff, the diagnosis of excessive alcohol intake usually goes unnoticed until drinking patterns have been firmly established and functioning impaired. In an attempt to develop a method of early identification of an individual at high risk of becoming alcoholic once enrolled in methadone maintenance, the following study was undertaken.
COHEN ET AL.
260
Am J Drug Alcohol Abuse 1977.4:257-266. Downloaded from informahealthcare.com by McMaster University on 11/03/14. For personal use only.
METHODS A modification of a self-administered alcohol screening test (SAAST) developed by Swenson and Morse [ 5 ] was utilized to assess an individual's potential for alcoholism. The test as formulated by these investigators was able to differentiate alcoholics from a nonalcoholic group of patients drawn from a general medical population. In the present study the SAAST was modified by the insertion of five questions designed to provide a measure of validity with respect to an individual's response to the overall questionnaire (Fig. 1). The five questions pertaining to drinking patterns differed slightly in content but required identical responses to five of the standard items in the questionnaire. The subtle changes in these items were made so that the patient might be unaware that the same answer was expected. The SAAST was given individually to each patient by a counselor. A yes or no answer was required for each of 34 items. The total score was obtained by a summation of the number of questions answered in the alcoholic direction, with the higher scores indicating a greater potential for alcoholism. Utilizing this system, excluding the five validity questions, the highest possible score would be 34. A validity score was obtained on the basis of whether the same answer was given to a test question and its corresponding validity question. Complete agreement between the five pairs of questions would result in a maximum score of five, while complete discordance would give a score of zero. The modified SAAST was administered to the following groups: (1) 30 patients enrolled in the MMATP who currently exhibited signs of severe alcoholism (Alcoholic Group), (2) 30 patients who were stabilized on methadone maintenance and were considered by their therapists to exhibit neither signs nor symptoms related to alcohol intake (Control Group); and (3) 80 consecutive admissions to the MMATP over a 6-month period (Admission Group). A comparison of scores on the SAAST was performed between the first two groups to corroborate the effectiveness of this test in separating alcoholic from nonalcoholic persons enrolled on methadone maintenance. Patients in the Admission Group were stratified on the basis of their SAAST score and followed for a period of up to 7 months to determine if a relationship could be established between SAAST score and development of alcoholism. A diagnosis of excessive alcohol intake was made on the basis of (1) a history of consuming increasing amounts of alcohol since enrollment and (2) presence of drunkenness when appearing in the clinic.
ALCOHOLISM SCREENING TEST
26 1
Am J Drug Alcohol Abuse 1977.4:257-266. Downloaded from informahealthcare.com by McMaster University on 11/03/14. For personal use only.
Tests for significance between groups were performed using Student’s t test and chi-square. A level of significance was considered to exist when p values were less than 0.05.
RESULTS Demographic analysis of the Alcohol and Control Groups revealed no significant differences with respect to sex, ethnicity, age, or years of narcotic addiction (Table 1). The Alcohol Group had a mean SAAST score of 14.03; the Control Group a mean score of 3.00 (p < .001) (Table 2). Mean validity scores were 3.3 and 4.3, respectively @ < .01). No person in the Control Group, however, had a SAAST score of more than 7 or a validity score of less than 3. The scores on the SAAST of the 80 persons in the Admission Group are illustrated in Table 3. The mean score was 5.17, compared to 3.00 for the Control Group (p < .01). It was hypothesized that the higher scores in this group might be explained by the presence of either hidden alcoholics or individuals with the potential for developing alcoholism at some time in the future. This group was therefore subdivided based on SAAST scores of zero to 7 and 8 or greater (Table 4). A score of 8 was selected as a cutoff point indicative of potential alcoholism as it represented a value greater than the range of the Control Group. Twentyone patients of the 80 (26%) in the Admission Group had scores indicative of Table 1. Demographic Characteristicsof Control and Alcoholic Populations Alcohol
Control
No. %
No. %
30
30
26 86 4 14
25 83 5 17
17 56 9 30 4 14
16 53 8 27 6 20
Mean age (years)
33
34
Mean years of narcotic addiction
12
10
Group
Total patients sex
Male Female Ethnicity Puerto Rican Black White
COHEN ETAL.
26 2
Table 2. Results of Self-Administered Alcohol Screening Test (SAAST)
Am J Drug Alcohol Abuse 1977.4:257-266. Downloaded from informahealthcare.com by McMaster University on 11/03/14. For personal use only.
SAAST scores Group Alcohol
No.
Mean score
30
14.03 f 5.35**
Control
30
SD
Validity scores Mean score SD
Range
3.00 f 1.72
4-23
3.3
0-7
4.3 f 0.70
f
1.05*
* p = .01. **p < .001.
Table 3. Comparison SAAST Scores between Admission and Control Group Mean score
No.
Range
Control
30
3.00 f 1.72*
0-7
Admission
80
5.17
0-22
*p
AM. J. DRUG ALCOHOL ABUSE, 4(2), pp. 257-266 (1977)
The Use of an Alcoholism Screening Test to Identify the Potential for Alcoholism in Persons on Methadone Maintenance AARON COHEN, M.S. WILLIAM McKEEVER, M.S. MURRY COHEN, M.D. BARRY STIMMEL, M.D. Departments of Medicine and Psychiatry Mount Sinai School of Medicine of The City University of New York New York, New York 10029
ABSTRACT Alcoholism has become a problem of increasing prominence in persons enrolled in methadone maintenance programs. Since early identification of the potential problem drinker may result in successful intervention, a method to screen individuals applying for admission to methadone maintenance who have a proclivity toward alcoholism would be of great value. A modified self-administered alcoholism screening test (SAAST), previously confirmed to identify “hidden alcoholics” in a general nonnarcotic-using population, was utilized as a screening device in three groups of narcotiodependent persons on methadone maintenance: 30 individuals who had a known problem with alcoholism, 30 individuals without any history or signs of alcoholism over an extended time period, and 80 persons entering methadone maintenance who initially denied any problems with excessive drinking. The ability of the modified SAAST to separate the alcoholic from the nonalcoholic narcotic addict was mnfiimed (p < 0.001). This test was also found to have considerable predictive value in determining those individuals initially denying a history of excessive alcohol intake who become problem drinkers.
257
COHEN ETAL.
258
Am J Drug Alcohol Abuse 1977.4:257-266. Downloaded from informahealthcare.com by McMaster University on 11/03/14. For personal use only.
Expected Alcoholic Response
+
1.
-
2.
+
3.
+
4.
Do close relatives ever worry or complain about your drinking?
-
5.
Can you stop drinking without a struggle after one or two drinks?
+
6.
-
7.
-
8.
+
9.
Do you ever feel guilty about your drinking? Do friends or relatives think you are a normal drinker? Are you always able to stop drinking when you want to? Have you every attended a meeting of Alcoholics Anonymous (AA) because of your drinking? Do you ever drink before lunch? (19) Have you gotten into physical fights when drinking? Has drinking ever created problems between you and your wife, husband, parent, or near relative? Has your wife, husband, or other family member ever gone to anyone for help about your drinking? Have you ever lost friends because of your drinking? Do you get rowdy when you drink? (11) Have you ever gotten into trouble at work because of your drinking? Have you ever lost a job because of your drinking? Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking? Do you ever drink in the morning? Have you ever felt the need to cut down on your drinking? Have there been times in your adult life when you have found it necessary to completely avoid alcohol? Have you ever been told that you have liver trouble (cirrhosis)? Have you ever had delirium tremens (DT’s)? Have you ever had severe shaking, heard voices, or seen things that weren’t there after heavy drinking? Have you every enjoyed a drink? (1) Have you ever gone to anyone for help about your drinking? Have you ever been in the hospital because of your drinking? Have you ever been told by a doctor to stop drinking?
10.
+ +
11.
+
13.
+
14.
+ + +
16.
+ + +
19.
12.
15.
+ + +
17. 18.
20. 21. 22. 23. 24. 25.
+ + +
26. 27. 28.
Do you enjoy a drink now and then? Do you feel that you are an average drinker? Have you ever awakened in the morning, after some drinking the night before, and found that you could not remember part of the evening?
ALCOHOLISM SCREENING TEST
259
Am J Drug Alcohol Abuse 1977.4:257-266. Downloaded from informahealthcare.com by McMaster University on 11/03/14. For personal use only.
Expected Alcoholic Response
+
29.
Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital?
+ +
30. 31.
Was drinking part of the problem that resulted in that hospitalization?
+
32.
Have you ever been arrested, even for a few hours, because of drunken behavior? How many times?
33.
Have you ever cut down on your drinking by switching to something else? (20)
34. 35.
Have you ever been told that you have a drinking problem? (4)
Have you ever been a patient a t a psychiatric or mental health clinic or gone to any doctor, social worker, or clergyman for help with any emotional problems?
Have you ever been arrested, even for a few hours, because of driving while intoxicated? How many times? Have any of the following relatives ever had problems with alcohol?
36. 31. 38. 39.
Parents Brothers and sisters Husband or wife Children
Fig. 1. Self-administered alcohol screening test (modified from Swenson and Morse IS]). Questions 10, 15, 25, 33, and 34 are validity questions with the number of the similar question indicated in the parenthesis.
The diagnosis of alcoholism, particularly in its early stages, is exceedingly difficult. Not infrequently, through denial on either the part of the patient or therapist, an advanced state of alcoholism is allowed to occur prior to its recognition. The prevalence of alcoholism in patients enrolled in methadone maintenance programs has been well described [l-41. Unfortunately, although these individuals are seen daily by treatment staff, the diagnosis of excessive alcohol intake usually goes unnoticed until drinking patterns have been firmly established and functioning impaired. In an attempt to develop a method of early identification of an individual at high risk of becoming alcoholic once enrolled in methadone maintenance, the following study was undertaken.
COHEN ET AL.
260
Am J Drug Alcohol Abuse 1977.4:257-266. Downloaded from informahealthcare.com by McMaster University on 11/03/14. For personal use only.
METHODS A modification of a self-administered alcohol screening test (SAAST) developed by Swenson and Morse [ 5 ] was utilized to assess an individual's potential for alcoholism. The test as formulated by these investigators was able to differentiate alcoholics from a nonalcoholic group of patients drawn from a general medical population. In the present study the SAAST was modified by the insertion of five questions designed to provide a measure of validity with respect to an individual's response to the overall questionnaire (Fig. 1). The five questions pertaining to drinking patterns differed slightly in content but required identical responses to five of the standard items in the questionnaire. The subtle changes in these items were made so that the patient might be unaware that the same answer was expected. The SAAST was given individually to each patient by a counselor. A yes or no answer was required for each of 34 items. The total score was obtained by a summation of the number of questions answered in the alcoholic direction, with the higher scores indicating a greater potential for alcoholism. Utilizing this system, excluding the five validity questions, the highest possible score would be 34. A validity score was obtained on the basis of whether the same answer was given to a test question and its corresponding validity question. Complete agreement between the five pairs of questions would result in a maximum score of five, while complete discordance would give a score of zero. The modified SAAST was administered to the following groups: (1) 30 patients enrolled in the MMATP who currently exhibited signs of severe alcoholism (Alcoholic Group), (2) 30 patients who were stabilized on methadone maintenance and were considered by their therapists to exhibit neither signs nor symptoms related to alcohol intake (Control Group); and (3) 80 consecutive admissions to the MMATP over a 6-month period (Admission Group). A comparison of scores on the SAAST was performed between the first two groups to corroborate the effectiveness of this test in separating alcoholic from nonalcoholic persons enrolled on methadone maintenance. Patients in the Admission Group were stratified on the basis of their SAAST score and followed for a period of up to 7 months to determine if a relationship could be established between SAAST score and development of alcoholism. A diagnosis of excessive alcohol intake was made on the basis of (1) a history of consuming increasing amounts of alcohol since enrollment and (2) presence of drunkenness when appearing in the clinic.
ALCOHOLISM SCREENING TEST
26 1
Am J Drug Alcohol Abuse 1977.4:257-266. Downloaded from informahealthcare.com by McMaster University on 11/03/14. For personal use only.
Tests for significance between groups were performed using Student’s t test and chi-square. A level of significance was considered to exist when p values were less than 0.05.
RESULTS Demographic analysis of the Alcohol and Control Groups revealed no significant differences with respect to sex, ethnicity, age, or years of narcotic addiction (Table 1). The Alcohol Group had a mean SAAST score of 14.03; the Control Group a mean score of 3.00 (p < .001) (Table 2). Mean validity scores were 3.3 and 4.3, respectively @ < .01). No person in the Control Group, however, had a SAAST score of more than 7 or a validity score of less than 3. The scores on the SAAST of the 80 persons in the Admission Group are illustrated in Table 3. The mean score was 5.17, compared to 3.00 for the Control Group (p < .01). It was hypothesized that the higher scores in this group might be explained by the presence of either hidden alcoholics or individuals with the potential for developing alcoholism at some time in the future. This group was therefore subdivided based on SAAST scores of zero to 7 and 8 or greater (Table 4). A score of 8 was selected as a cutoff point indicative of potential alcoholism as it represented a value greater than the range of the Control Group. Twentyone patients of the 80 (26%) in the Admission Group had scores indicative of Table 1. Demographic Characteristicsof Control and Alcoholic Populations Alcohol
Control
No. %
No. %
30
30
26 86 4 14
25 83 5 17
17 56 9 30 4 14
16 53 8 27 6 20
Mean age (years)
33
34
Mean years of narcotic addiction
12
10
Group
Total patients sex
Male Female Ethnicity Puerto Rican Black White
COHEN ETAL.
26 2
Table 2. Results of Self-Administered Alcohol Screening Test (SAAST)
Am J Drug Alcohol Abuse 1977.4:257-266. Downloaded from informahealthcare.com by McMaster University on 11/03/14. For personal use only.
SAAST scores Group Alcohol
No.
Mean score
30
14.03 f 5.35**
Control
30
SD
Validity scores Mean score SD
Range
3.00 f 1.72
4-23
3.3
0-7
4.3 f 0.70
f
1.05*
* p = .01. **p < .001.
Table 3. Comparison SAAST Scores between Admission and Control Group Mean score
No.
Range
Control
30
3.00 f 1.72*
0-7
Admission
80
5.17
0-22
*p
