Opportunistic screening for alcohol use disorders in primary care: comparative study

BMJ 2006; 332 doi: (Published 02 March 2006) Cite this as: BMJ 2006;332:511

Selection Bias was major limitation

Dear Editor

In the brave new world of a National Health Service where 'value for
money' is tantamount, the authors are to be commended for their
methodology in using a number of valid clinical outcome measures for
alcohol misuse and dependence and comparing these to more traditional
biochemical variables that are commonly used in both primary and secondary
care. However, some caution is required in interpreting the results in
light of the methodology.

Firstly, as the AUDIT is made up of questions that assess aspects of
alcohol use such as quantity/frequency and dependence, it is hardly
surprising that its internal validity when measured against outcomes such
as binge drinking and alcohol dependence is high in ROC analyses. In
fact, a more clinically meaningful outcome parameter that may of more
relevance to primary care would be the presence of problems consequent
upon drinking, which could have been ascertained using a rating scale such
as the Drinking Problems Index (1). Secondly, the selection of male
drinkers is a major source of bias, as it is known that traditional
screening tools such as the AUDIT show low sensitivity in detecting
alcohol misuse in women (2)and older people (3). This study would need
further replication is both these populations, as well as in inner-city
areas where populations show greater cultural diversity.

Although a major contribution to detection and screening of alcohol
use disorders in primary care, clinicians should be mindful of the wider
population, otherwise the general public may be misinformed in the same
way as they have with the public health message of alcohol and
cardioprotection, which, again, only applies to a section of the


(1) Finney, J.W., Moos, R.H. & Brennan, P.L. The Drinking
Problems Index: A measure to assess alcohol-related problems among older
adults. J Subst Abuse 1991;3:395-404

(2) Arndt, S., Schultz, S.K., Turvey, C., Petersen, A. Screening for
Alcoholism in the Primary Care Setting: Are We Talking to the Right
People? J Fam Prac 2002;51:41-6.

(3) Morton, J.L., Jones, T.V., Manganaro, M.A. Performance of
alcoholism screening questionnaires in elderly veterans. Am J Med

Competing interests:
None declared

Competing interests: No competing interests

03 March 2006
Rahul Rao
Consultant/Senior Lecturer
York Clinic, Guy's Hospital, London SE1