In a recent systematic review published in the journal JAMA, researchers evaluated the diagnostic accuracies of screening tools for alcohol usage disorder (AUD) using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria.
Alcohol usage is a primary cause of accidents, infections, and cancer, especially among young and elderly individuals. Pregnant women have an increased risk of fetal alcohol syndrome. Screening rates for alcohol use disorder (AUD) are low, warranting the re-evaluation of the accuracy of screening tests to fit with the DSM-5 criteria. New case definitions have an impact on the accuracy of existing screening instruments, with 12% to 61% fewer individuals identified with AUD than those diagnosed using DSM-IV criteria. Understanding non-harmful drink numbers and terminology is necessary for assessing excessive alcohol usage.
In the present systematic review, researchers conducted qualitative (systematic literature review) and quantitative (meta-analysis) research to assess the diagnostic accuracy of AUD screening tools using DSM-5.
Does This Patient Have Alcohol Use Disorder? The Rational Clinical Examination Systematic Review. Image Credit: Syda Productions / Shutterstock
Clinical case scenario and methodology
An 18-year-old lady visits her healthcare physician with anxiety symptoms she believes are the result of personal life stress. Her systolic/diastolic blood pressure is 145/90 mmHg, and her heart rate is 100 beats per minute. She exhibits minor trembling, which she attributes to anxiety over the visit. Her medical history is disease-free, although she admits to drinking alcohol at least once a week, "mostly when out with friends." The doctor wonders how much more information might be obtained from basic screening instruments to determine her AUD risk.
The researchers searched the Embase and MEDLINE databases for original research evaluating the diagnostic accuracies of AUD screening tools following DSM-5 guidelines published in English between January 1, 2013, and February 24, 2023. They retained studies with screening tools identifying high-risk or excessive alcohol intake among individuals aged 9.0 to 18 years, those aged ≥65 years and expecting women since AUD diagnosis does not include excessive alcohol intake as a screening criterion. The researchers calculated likelihood ratios (LR), specificity, and sensitivity. They also conducted meta-analytical research to derive a cumulative LR.
Two researchers independently reviewed the data using the Rational Clinical Examination evidence levels to assess study quality. They used the Quality Assessment of Diagnostic Accuracy Studies tool to evaluate the risk of bias. They assessed the estimated prevalence of high-risk alcohol usage and AUD in the general public from the United States Substance Abuse and Mental Health Services Administration estimates and calculated the pooled prevalence using random-effects models.
Results and Scenario Resolution
From the 4,303 identified studies, the researchers retained 35, including 79,633 individuals, of whom 11,691 consumed alcohol excessively or were diagnosed with AUD. Among the 35 included studies, the overall prevalence of AUD was 19% in adults, 21% in young people, 25% in women, 33% in men, and 8.1% in pregnant individuals.
Across ages, a ≥8.0 score on the AUD Identification Test (AUDIT) elevated AUD likelihood (LR, 6.50). Positive screening results using the AUDIT tool identified AUD better among women (LR, 6.90) than men (LR, 3.80). A <8.0 AUDIT score reduced the AUD likelihood by comparable magnitudes for both genders (LR, 0.3). The AUDIT-Consumption (AUDIT-C) test has a gender-specific threshold of ≥4.0 for men and ≥3.0 for women but showed lower utility for AUD identification (LRs of 1.8 and 2.0 for males and females, respectively). AUDIT-C seemed beneficial for identifying excessive alcohol intake among individuals aged 9.0 to ≤18 years and those aged >60 years.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) pediatric age-specific alcohol intake cut-offs helped estimate AUD likelihood at the lowermost risk cut-off (LR, 0.2), at moderate-level AUD risk cut-off (LR, 3.40), and the uppermost risk cut-off (LR, 15). Among pregnant women screened within two days postpartum, AUDIT scores of ≥4.0 identified individuals likely to develop AUD (LR, 6.40), whereas scores below 2.0 in the Tolerance, Annoyed, Cut-Down, and Eye-Opener (T-ACE) and the Tolerance, Worried, Eye-Opener, Amnesia, and Cut-Down (TWEAK) screening tools identified AUD to a similar extent (LR, 0.1).
Non-specific clinical signs such as hypertension and symptoms such as anxiety may result from excessive alcohol consumption. According to the NIAAA instrument, the female patient reported drinking once per week over the previous year as a positive screening result with an LR of 15, increasing the likelihood of AUD to between 60% and 72%. With this screening result, physicians should undertake a thorough DSM-5 diagnostic interview. If the DSM-5 diagnostic interview results are positive, she should receive guideline-directed therapies appropriate to the severity of her AUD. If the DSM-5 diagnostic interview does not indicate AUD, the therapist should inquire about her drinking habits and offer advice on the hazards of alcohol consumption and ways to reduce usage.
Based on the systematic review findings, the AUDIT tool can identify AUD among adults and individuals within two days of delivery. The NIAAA tool helps identify pediatric and adolescent AUD cases. AUDIT-C could benefit excessive alcohol intake identification among youngsters and older individuals.
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