Navigation

Drug And Alcohol Classes

INTRODUCTION

Rates of alcohol and drug use have been shown to differ across various racial and ethnic groups. [1] There are also differences in performance on screening instruments for alcohol and/or drug abuse among between different racial and ethnic groups. One study examined the rates of alcohol problems for white, black, and Hispanic men for the years 1984 and 1995. [2] The rates of three or more alcohol problems for men of each ethnic group for 1984 and 1995 were: 12 and 11% for white men, 16 and 13% for black men, and 9 and 16% for Hispanic men, respectively. Rates of frequent heavy drinking and alcohol-related problems have remained especially high among black and Hispanic men, suggesting that men of these two ethnic groups should be specifically targeted for renewed prevention efforts. [2]

Another study examined cut points for the CAGE, Brief MAST, AUDIT, and TWEAK alcohol screening instruments against ICD-10 criteria in an emergency room population, [3] The results of this study show that these instruments did not perform equally well across ethnic groups and that the optimal cut point on an alcohol screening may differ for certain ethnic groups. For instance, a cut point of 1 on the CAGE performed better than the standard cut point of 2 for both the white and black emergency room patients. Also, the optimal cut points for women on the TWEAK and the CAGE in this study were found to be 2 and 1, respectively, rather than the standard cut points of 3 and 2, respectively. The authors concluded that it should not be assumed that existing screening tests will perform equally well across ethnic subgroups.

The National Household Survey on Drug Abuse has examined the prevalence of substance use by race and ethnicity. [1] This survey examined the prevalence of substance use, alcohol dependence, and need for illicit drug abuse treatment within 11 racial and ethnic subgroups while statistically controlling for many sociodemographic characteristics. Past year illicit drug use and need for illicit drug abuse treatment was found to have a relatively high prevalence among blacks (non-Hispanic: 13%) and an intermediate prevalence among whites (non-Hispanic). Past year cocaine use was relatively high among blacks (3.1%), with the peak prevalence among this group occurring at ages 26-34 (6.1%). Past year cocaine use by whites was found to be high especially among those ages 18-25 (7%). Licit substance use (including measures of cigarette and alcohol use) was found to be high in whites.

Current Study

The current study examines ethnic differences of responses to The Health and Safety Screen and The Drug Abuse Problem Assessment for Primary Care (DAPA-PC), a computerized screening instrument for alcohol and other drug use and abuse. There are a couple of unique aspects of the current study. To the best of the authors' knowledge, this study is the first to examine differences in responses by ethnic group to a screening that assesses not only alcohol use, but illicit drug use as well. In our review of the literature, the majority of studies have compared ethnic groups responses and performance on screening instruments for alcohol use only. Furthermore, this study is the first to examine the performance of an alcohol and other drug use screening instrument for blacks and whites in a primary care facility. Previously, studies have often concentrated on alcohol use and/or abuse only, and often in individuals with established alcohol abuse and/or dependence. Few studies examined the substance use screening instruments in a primary care setting. Responses to the screening instruments will also be examined to determine if the current screening criteria is appropriate for both groups.

The Drug Abuse Problem Assessment for Primary Care

Recognizing the need for increased screening of patients for risk of substance abuse and dependence problems, Danya International, in Silver Spring, Maryland developed the DAPA-PC under a contract from the National Institute on Drug Abuse. The DAPA-PC system is an easily implemented, comprehensive resource for drug abuse screening in a primary care setting. The DAPA-PC is a self-administered, internet-based screening instrument, which features automatic scoring, generation of a patient profile for medical reference, and presentation of unique motivational messages and advice to the patient. A detailed description of the development process of the DAPA-PC can be found in Ref. [4].

The DAPA-PC system is designed as a two-level screening instrument. All users of the DAPA-PC system begin by answering a very brief risk and trauma assessment called The Health and Safety Screen. Specific effort was made to include questions, which were sensitive to the needs of women and minority groups. A patient's score on The Health and Safety Screen will determine whether the patient will be moved into the second level of the system, The Drug and Alcohol Problem Screen. The patient will continue in the system if he or she:

   responds positively to any two questions; or
   reports drug use; or
   reports an average number of drinks per sitting as greater than 6.

The second level of the DAPA-PC system is The Drug and Alcohol Problem Screen. The DAPA-PC scoring is based on the following criteria:

   No positive answers = no problem/advice: even if no positive answers
   are given at this level of the screen, the patient may still have a
   risk for substance abuse. A brief message of advice that warns the
   patient about the risks of alcohol/other drug use is provided.

   One or two positive answers = risk for substance abuse/brief
   intervention: if the patient responds positively to one or two
   questions on this level of the screen, she or he will receive a
   brief motivational intervention on the computer.

   Three or more positive answers = risk for substance
   dependence/treatment/referral: if the patient responds positively to
   three or more questions on this level of the screen, or there is
   indication of abuse of more than one drug, the patient receives a
   motivational message to seek treatment from his or her primary care
   provider.

A total score on the DAPA-PC is obtained by adding all of the positive responses to the yes/no questions on The Drug and Alcohol Problem Screen and two questions specific to substance use, ranging from 0 to 10 (1 point for each positive response). Therefore, higher scores indicate being at greater risk for drug/alcohol problems.

After completion of the Drug and Alcohol Problem Screen, information is posted indicating whether someone's health is at risk from drinking alcohol or using drugs. If a health risk is indicated, advice and options on how to minimize this risk will be displayed. Useful health links are displayed for the patient to explore. Finally, for the provider, a summary of the patient's results is provided. In addition, useful links are given for the primary care provider.

The psychometric properties of the DAPA-PC have been examined and evidence supporting its reliability and validity for identifying subjects at risk for alcohol or drug use problems in a primary care setting has been found. [5] This instrument could have important public health implications and cost savings if implemented on a wide-scale basis, particularly because it is computer-based, which may increase the likelihood of patients responding more openly to the questions being asked.

METHODS

Participants were recruited from a diverse population presenting for care at the George Washington University Medical Faculty Associates clinic in downtown Washington, DC. Participants had to be over 18 years of age to be eligible for the study. Demographic information collected included age, ethnicity, educational level, profession, and contact information. Two trained research assistants with Bachelor's degrees in a related discipline (psychology, social work) recruited the subjects and collected data. Informed consent was obtained from all the study participants prior to data collection and participation was completely voluntary. Participants were asked to complete the instruments in a private office outside the waiting area of the medical practice.

Measures

1. The Health and Safety Screen is a very brief risk and trauma assessment that aids in determining a patient's level of drug and alcohol abuse in a predictive yet nonthreatening way. The items on this instrument are likely to be answered more honestly because they do not overtly address substance abuse. This screen also allows the provider to explore drug and alcohol-related issues such as depression or physical/emotional abuse.

2. The Drug and Alcohol Problem Screen, the second level screen of the DAPA-PC system, focuses on drugs and alcohol problems directly.

3. Urine and Hair Specimens were used to identify the physiological presence of drugs or alcohol. The urinalysis was used as the external criteria for recent use (1-2 days) providing short-term validity. Urine analysis was completed using the OnTrak TesTcup5 from Roche Diagnostic System, Indianapolis, IN, USA, which can identify exposure of all major drug classes in the past 2-3 days. Hair analysis, conducted by Psychemedics Corporation, Culver City, CA, USA, was used to identify exposure to drugs in the 90 days prior to the interview.

Sample Description

Data were collected from 289 participants, 53% were white, and 46% were black. Forty-eight percent of the white participants were male and 52% were female. Thirty-seven percent of the black participants were male and 63% were female. Analyses were conducted to compare the black and white participants in terms of other demographic characteristics. The average age of the black and white participants were 40 and 43, respectively. Average educational level was 15 years for white participants and 14 years for black participants. Marital status was similar for both the ethnic groups, with 79% of white participants not married, and 78% of black participants not married. Overall, there were no differences found between the two ethnic groups in the demographic variables.

Analyses

Responses of white and black participants were compared for the DAPA-PC system, including The Health and Safety Screen, The Drug and Alcohol Problem Screen, and hair and urine results. Bivariate analyses including chi-square tests to compare categorical variables and t-tests to compare continuous variables were used.

RESULTS

Responses by ethnic group are reported below, beginning with the results of The Health and Safety Screen, followed by The Drug and Alcohol Problem Screen, and lastly the results of the hair and urine analyses.

The Health and Safety Screen

Differences were found in responses by ethnic group in 25%, or 3 out of 12 of the items on The Health and Safety Screen (Table 1). There were no differences between the two groups on the remaining items, including those regarding broken bones, injury in a car accident, head injury, physical/emotional harm, small accidents, depression, drug use, tobacco use, or number of drinks consumed on a typical occasion.

White participants were more likely than black participants to respond positively to the question regarding having drunk alcohol in the past 5 years (87 vs. 70%, p < 0.01), although both groups reported an average of two drinks on a typical occasion. Black participants were twice as likely to report having been in a physical fight (24 vs. 12%, p < 0.05) and also more likely to report that someone important to them had a problem with alcohol or other drugs (59 vs. 47%, p < 0.01). There were no significant differences between the two groups on any of the three scoring criteria for The Health and Safety Screen (Table 1). In addition, the overall score on The Health and Safety Screen did not significantly differ between the two groups.

The Drug and Alcohol Problem Screen

The two ethnic groups significantly differed in their responses on two yes/no items of The Drug and Alcohol Problem Screen and in responses to the items regarding which substance they used most and frequency of use of the substance used second most. White participants were more likely than black participants to report that they had used alcohol and/or other drugs in the past 30 days (68 vs. 52%, p < 0.05) (Table 2). However, black participants were almost twice as likely as white participants to report that they had tried to quit alcohol and/or drugs within the past 6 months (30 vs. 17%, p < 0.05) and more than twice as likely than white participants to report that they had spent a lot of time thinking/trying to get alcohol and/or other drugs (9 vs. 4%, p < 0.05). Sixty-seven percent of black participants who indicated that they spent a lot of time thinking/trying to get alcohol and/or other drugs indicated that the drug they used most was a drug other than alcohol (i.e., illicit drugs) (see Table 2). Eighty-three percent of white participants who indicated that they spent a lot of time thinking/trying to get alcohol and/or other drugs indicated that alcohol was the drug they used most (see Table 2). Fifty percent of black participants who indicated that they had tried to quit alcohol and/or other drugs indicated that alcohol was the drug they used most. Forty percent of this group indicated that they used a drug other than alcohol most (i.e., illicit drugs). Eight-five percent of white participants who indicated that they had tried to quit alcohol and/or other drugs indicated that alcohol was the drug they used most.

White participants were more likely than black participants to report that alcohol was the substance they used most (69 vs. 40%, p < 0.01). Black participants were twice as likely as white participants to report that a drug other than alcohol was the substance they used most (20 vs. 10%, p < 0.01). However, black participants were twice as likely to report that they did not use any substance (40 vs. 20%, p < 0.01).

The two ethnic groups were similar in responses on items regarding feeling that they used too much alcohol/drugs, having withdrawal symptoms, not remembering things, problems at school/work due to drugs, arrested/legal problems, and others being concerned about their drug use. The overall scores on the DAPA-PC instrument (range of 0-10) for the two groups did not differ significantly.

Urine and Hair Specimens

Black participants were significantly more likely than white participants to have a positive urine or hair result for illicit drug use (36 vs. 13%, p < 0.01). Positive results of both the hair and urine tests for cocaine/crack were significantly higher for black participants (24 vs. 1%, p < 0.01; 4 vs. 0%, p < 0.05, respectively). Black participants were significantly more likely than the white participants to have a positive hair test for opiate use (13 vs. 2%, p < 0.01).

DISCUSSION

The conclusions of this study are similar to those of other studies examining substance use screening instruments in that the current results suggest that substance use behaviors may vary for different ethnic groups. [1-3,6] In the current study, several significant differences in responses were found for blacks and whites on the two screening instruments that make up the DAPA-PC system (The Health and Safety Screen and The Drug and Alcohol Problem Screen). Overall, however, the DAPA-PC instrument appears to be a useful screening instrument for identifying both blacks and whites who use or abuse alcohol and/or other drugs.

Results of several studies have shown that popular screening instruments for alcohol use and abuse may be ethnically biased. While the current study of the DAPA-PC system found that several items of this screening instrument result in different response rates for black and white participants, the overall screening criteria appeared to work for both groups. There was no significant difference in scoring on The Health and Safety Screen between the two groups on any of the three scoring criteria. However, there were differences by ethnic group on three of the items in The Health and Safety Screen. More black participants responded positively to the items regarding having been in a physical fight and someone important to them having had a problem with drugs, while white participants were more likely to indicate that they drank alcohol. As a result, it appears that different questions on The Health and Safety Screen were responded to positively by the two ethnic groups. In the development of alcohol and/or other drug screening instruments, it is important to keep in mind that different risk factors may affect various ethnic groups. Therefore, issues that affect different ethnic groups should be taken into consideration in the development of new screening instruments and incorporated into the development of the screening instrument items and scoring decisions.

On The Drug and Alcohol Problem Screen, black participants scored higher than white participants on items regarding having tried to quit and spending lots of time thinking/trying to get drugs. A probe of this result showed that of those respondents who indicated that they tried to quit, most whites reported alcohol as the drug they used most, while blacks were less likely than whites to report alcohol and more likely than whites to report other drugs. The same result occurred for black and white respondents who indicated that they spent a lot of time either thinking about or trying to get alcohol and/or other drugs. This is not surprising in light of the results of the National Household Survey on Drug Abuse, in which illicit drug use and need for illicit drug abuse treatment was found to have a relatively high prevalence among blacks. [1] This is an important result that should be considered in the development of screening instruments that assess both alcohol and other drug use in ethnically heterogeneous populations. While the current study did not address differences in responses for other ethnic groups on the DAPA-PC system (due to small sample sizes for other ethnic groups), this may be an area of further research. The results of the current study suggest that it may be advantageous to create ethnically specific motivational messages and highlight the importance of making culturally appropriate referrals.

There is evidence that computerized lifestyle tests, such as the DAPA-PC, appear to be an acceptable method for both men and women with different educational backgrounds. [7] A study by Aquilino [8] suggests that the anonymity provided by self-administered questionnaires, such as the DAPA-PC, appears to increase respondents' willingness to reveal sensitive behavioral information, especially among minority ethnic groups. [8] In addition, computerized assessments encouraged patients to take the interview more seriously, likely by decreasing fears of the patient that the interviewer may be judgmental regarding his or her alcohol and/or other drug use. [9] While patients might modify their answer regarding alcohol and/or other drug use or misuse in a traditional interview setting, patients appear to feel that they are being taken seriously and not being judged when behaviors related to alcohol use are assessed by a computer. The fact that black participants were more likely to test positive for illicit drug use in the hair/urine test results and were more likely to report illicit drug use on the DAPA-PC instrument further supports this notion that ethnic minority groups are willing to reveal sensitive behavioral information on computerized screening instruments, such as the DAPA-PC.

The DAPA-PC computerized screening instrument provides a unique, brief motivational intervention to patients who are at risk for substance use or abuse. The patient will still receive a brief intervention even if he or she does not discuss his or her results with the primary care provider or seek treatment or other help. This is especially important due to the fact that research examining the ethnic variations in perceived need for treatment and utilization of drug abuse treatment has shown that black drug users are more likely than whites to hold unfavorable view of treatment and less likely to perceive a need for treatment. [10,11]

The results of the current study suggest that the established cut-off points for the DAPA-PC instrument are acceptable for both blacks and whites. However, other studies examining alcohol use screening instruments reported that it may be necessary to adjust cut points for different ethnic groups. [3] Clinicians utilizing these instruments should be mindful of these differences and should make necessary adjustments in their practice for individuals of different ethnic groups. Furthermore, individuals designing future instruments for alcohol and/or other drug use and abuse should be aware of these differences and, where necessary, adapt the instrument to different ethnic groups. It is important to recognize that one alcohol and/or other drug abuse screening instrument is not always applicable to all persons in all settings.

Table 1. Responses to Health and Safety (H&S) Screen by Race

                                         White (%)   Black (%)
Health and Safety Items (Past 5 Years)   (n = 154)   (n = 135)

Broken bones                                17          19
Injured in car accident                     13          20
Head injury                                 10          11
Physical fight                              12 *        24 *
Physical/emotional harm                     34          35
Small accidents                             23          24
Down/depressed                              38          42
Someone important, problem                  47 **       59 **
  with drugs
Used drugs                                  29          35
Smoked/chewed tobacco                       45          44
Drunk alcohol                               87 **       70 **
Typical occasion, # drinks                   2           2
Scoring:
  Responded positive to any                 88          83
    two questions
  Responded positive to drug use            29          35
  Reported > 6 drinks on                     4           7
    typical occasion
  Total score (0-11)                        3.5         3.8

* p < 0.05; ** p < 0.01.

Table 2. Responses to Drug and Alcohol Problem (DAP) Screen by Race

Drug and Alcohol Problem Questions              White       Black
(in Past 6 Months)                            (n = 154)   (n = 135)

Felt used too much alcohol/drugs                 14          19
Tried to quit                                    17 *        30 *
Had withdrawal symptoms                           5          12
Did not remember things                          16          18
Drugs [right arrow] problems at school/work       8          12
Arrested/legal problems                           3           6
Lot of time thinking/trying                       4 *         9 *
  to get drugs
Others concerned about your drug use              9          14
Substance used most **
  None                                           21          40
  Alcohol                                        69          40
  Other drug (marijuana, cocaine,                10          20
    opiates, sedatives, LSD, or other)
Substance used second most
  None                                           76          76
  Alcohol                                         9           5
  Other drug (marijuana, cocaine,                15          19
    opiates, sedatives, LSD, or other)
Frequency of use of substance
    used most (past 30 days)
  None                                           32          48
  One per month                                  16          16
  Weekly                                         21          10
  2-3x per week                                  22          13
  Daily                                           8          13
Frequency of use of substance
    used second most (past 30 days) *
  None                                           81          79
  One per month                                   8           5
  Weekly                                          7           3
  2-3x per week                                   3           5
  Daily                                           1           8
Scoring
  No positive answers                            72          65
  1-2 positive answers                           17          16
  3 or more positive answers                     11          19
Total DAPA-PC system score                        1.78        2.03
  (mean, 0-10 range)

* p < 0.05; ** p < 0.01.

ACKNOWLEDGMENTS

The DAPA-PC screening instrument was developed with funding from a Small Business Innovative Research Grant, Phases I and II, from the National Institute on Drug Abuse, contract number N44DA86505. We would like to thank Dan Morgan and Shazia Masoodi for their assistance in the data collection process.

REFERENCES

[1.] SAMHSA. National Household Survey on Drug Abuse. Office of Applied Studies 1999, Available Online at http://www.samhsa.gov/oas/nhsda.htm, accessed June 17, 2002.

[2.] Caetano, R.; Clark, C.L. Trends in Alcohol Consumption Patterns Among Whites, Blacks and Hispanics: 1984-1995. Alcohol Clin. Exp. Res. 1998, 22 (2), 534-538.

[3.] Cherpitel, C.J. Analysis of Cut Points for Screening Instruments for Alcohol Problems in the Emergency Room. J. Stud. Alcohol 1995, 56 (6), 695-700.

[4.] Holtz, K.; Landis, R.D.; Nemes, S.; Hoffman, J. DAPA-PC: Development of a Computerized Screening System to Identify Substance Abuse in Primary Care. J. Health Care Qual. 2001, 23 (3), 34-37.

[5.] Nemes, S.; Landis, R.; Zeiler, C.; Holtz, K.; Hoffman, J. Online Drug Problem Screen for Primary Care: Psychometric Testing and Patient Responses. International Council on Alcohol and Addictions. Heidelberg, Germany. Sept. 2001.

[6.] Steinbauer, J.R.; Cantor, S.B.; Holzer, C.E., 3rd.; Volk, R.J. Ethnic and Sex Bias in Primary Care Screening Tests for Alcohol Use Disorders. Ann. Intern. Med. 1998, 129 (5), 353-362.

[7.] Bendtsen, P.; Timpka, T. Acceptability of Computerized Self-Report of Alcohol Habits: A Patient Perspective. Alcohol Alcohol. 1999, 34 (4), 575-580.

[8.] Aquilino, W.S. Interview Mode Effects in Survey of Drug and Alcohol Use: A Field Experiment. Publ. Opin. Q. 1994, 58 (2), 210-240.

[9.] Duffy, J.C.; Waterton, J.J. Under-Reporting of Alcohol Consumption in Sample Surveys: The Effect of Computer Interviewing in Fieldwork. Br. J. Addict. 1984, 79 (3), 303-308.

[10.] Longshore, D.; Hsieh, S.C.; Anglin, M.D.; Annon, T.A. Ethnic Patterns in Drug Abuse Treatment Utilization. J. Ment. Health Admin. 1992, 19 (3), 268-277.

[11.] Longshore, D.; Hsieh, S.; Anglin, M.D. Ethnic and Gender Differences in Drug Users' Perceived Need for Treatment. Int. J. Addict. 1993, 28 (6), 539-558.

Christine A. Zeiler, * Susanna Nemes, Kristen D. Holtz, Richard D. Landis, and Jeffrey Hoffman

Danya International, Inc., 8737 Colesville Road, Suite 1200, Silver Spring, MD 20910

* Corresponding author. Fax: (301) 565-3710; E-mail: czeiler@danya.com

COPYRIGHT 2002 Marcel Dekker, Inc.
COPYRIGHT 2003 Gale Group