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An alcohol and drug history should be included in the initial assessment, for example using the CAGE questionnaire or Trauma questions, to assess potential for substance abuse problems [47, 42, 48].

The Trauma Test is another screening tool used to assess the potential for substance abuse. It is a noninvasive method of obtaining information that can provide an important adjunct to diagnosis, and its brief structure provides a cost-effective screening procedure in clinical practice. The Trauma Test is composed of the following five questions:

Since your 18th birthday, have you:

1. Had any fractures or dislocations to your bones or joints (excluding sports injuries)?

2. Been injured in a traffic accident?

3. Injured your head (excluding sports injuries)?

4. Been in a fight or assaulted while intoxicated?

5. Been injured while intoxicated?

A positive response to two or more questions indicates a strong potential for alcohol abuse. Clinicians should use this tool in conjunction with laboratory tests and a brief questionnaire that directly inquires about problems related to alcohol use [42, 48].

Collateral information can be obtained from family, employers, and previous medical records [42]. Sudden loss of a job or frequent job changes for no apparent reason is often a consequence of substance abuse [42]. Unexplained financial or family problems can also result from substance abuse. Patients with a history of driving under the influence or a history of two or more non-sport-related traumatic events (after age 18 years) are considered at high risk for substance abuse [42]. Therefore, the prescribing physician should be alert to the eating disorder, addiction, and sexual abuse triad - if two are present, look for the third [49]. It is because of this triad that researchers have recommended that all women entering substance abuse treatment should be screened for eating disorders [50]. During the initial assessment ask for the following:

1. Has drug/alcohol use ever contributed to a problem for them or those close to them?

• Incorporate CAGE and Trauma questions into patient interview

2. Gather collateral information from a. Family b. Work c. Legal medical records

3. Be alert to the eating disorders, addiction, and sexual abuse triad. If two are present, look for the third.

The National Institute of Alcohol Addiction and Abuse recommend use of the CAGE questionnaire for possible alcohol problems. Clinicians should then ask the quantity and frequency questions of all patients who drink alcohol [51, 52]. If two of four questions are positive, diagnosis of a history of alcohol abuse or dependency has a sensitivity of 74% and a specificity of 91%:

1. Have you felt the need to cut (C) down on your drinking (or drug use)?

2. Have people annoyed (A) you by criticizing your drinking (or drug use)?

3. Have you ever felt bad or guilty (G) about your drinking (or drug use)?

4. Have you ever needed an eye-opener (E) the first thing in the morning to steady your nerves or get rid of a hangover?

Another test is the CRAFT, a screening instrument for problematic adolescent substance use. It is a six-question, "yes" or "no" type questionnaire. Like the CAGE, the CRAFT takes about one minute to complete, and can be incorporated into any type of evaluation [53]. While items 1, 2, and 5 pertain to personal drinking or drugging, and are heavily endorsed by adolescents with substance use disorders, only item 6 relates directly to the criteria for abuse [53]. A CRAFT score of two or higher is optimal for identifying problem use, abuse, or dependence having a sensitivity 76% and a specificity 94%. Positive screens should be followed by a more complete substance use history [54].

CRAFT is a developmentally appropriate screening tool for adolescents [54]. It is verbally administered, simple to score, and easy to remember. CRAFT is composed of the following six questions:

1. Have you ever ridden in a car (C) driven by someone (including yourself) who was "high" or had been using alcohol or drugs?

2. Do you ever use alcohol or drugs to relax (R), feel better about yourself, or fit in?

3. Do you ever use alcohol or drugs while you are alone (A)?

4. Do you ever forget (F) things you did while using alcohol or drugs?

5. Do your family or friends (F) ever tell you that you should cut down on your drinking or drug use?

6. Have you ever gotten into trouble (T) while you were using alcohol or drugs? This tool offers clinicians a practical means of identifying adolescent patients who need more comprehensive assessment or referral to substance abuse treatment specialists [54].

An optimal marker of excessive alcohol consumption has not been found. Although -yGT is the most widely used test as a marker, however, elevated levels are also caused by nonalcoholic liver disease, most hepatobiliary disorders, obesity, diabetes mellitus, hypertriglyceridemia, and the use of liver microsome-inducing drugs [55]. Also, elevated Mean Corpuscular Volume (MCV) is another frequently used marker for alcohol abuse. Combinations of more than one marker give better sensitivity. Determining both MCV and -yGT levels greatly improves the estimate of daily consumption. In particular, it permits tracking of false-negative subjects who exhibit low -yGT levels despite high alcohol consumption [56].

In alcoholic hepatitis, the activity of serum alanine aminotransferase (ALT) is depressed relative to that of aspartate aminotransferase (AST). An AST: ALT ratio greater than 2 may indicate alcoholic hepatitis [45]. There are initial laboratory assessments directing to a potential addiction liability:

1. Elevated a. -yGT (or other liver function tests)

b. MCV (mean corpuscular volume)

2. Detectable blood alcohol concentration

3. Elevated -yGT + MCV highly suggestive of alcoholism

4. AST: ALT ratio > 2 may indicate alcoholic liver disease -yGT = gamma-glutamyltranspeptidase;

MCV = mean corpuscular volume; AST = aspartate aminotransferase; ALT = alanine aminotransferase

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