Elena Silberman Scott, MA, MS, LCPC, CADC
5th year doctoral student at Adler University with a concentration in Health Psychology
The connection between alcohol misuse and negative health consequences is well established. Most major medical associations, including the American Medical Association and the World Health Organization advocate for screening as part of ongoing and regular care (Yoast et al., 2008; McPherson & Hersch, 1999). But are professionals asking the “right” screening questions? The focus in screening tends to be on quantity and frequency of use (i.e. how much and how often someone drinks). While this basic question is easy to administer, the answer does not necessarily identify individuals at risk for alcohol misuse accurately (McNeely & Hamilton, 2022; McPherson & Hersch, 1999).
Many individuals reply to screening questions by responding with number of “drinks,” which can lead to inaccuracy in reporting. While there is some consistency in drink amount when a drink is served at a restaurant or bar, at-home serving sizes may vary considerably (Boniface & Shelton, 2013). Is one drink a standard shot of hard liquor, a glass of wine, or a craft beer? Outside of the amount of drink, there is also variability in the alcohol content. Beer can range from 4-7% alcohol by volume, wine from 4-17%, and liquor from 28-60%. Furthermore, there is often a concern about underreporting in self-reports.
If quantity and frequency are not accurate screeners for potential misuse, what is? There are many screening instruments which have been shown to meet face validity and reliability criteria, although they appear to be best at identifying individuals who are open about their usage (Piazza et al., 2000). Part of the importance of screening is to identify individuals who may or may not be aware of potentially problematic alcohol consumption (Stewart & Connors, 2004).
One measure is slightly different in its approach. The Drinking Related Internal and External Locus of Control (DRIE) (Donovan & O’Leary, 1978) focuses on how an individual views their drinking behaviors. Rather than asking about actual alcohol consumption, it focuses on how individuals perceive the impact of their alcohol consumption on their life; namely, do they see drinking as a behavior within their control, or as a cause-and-effect response? This type of locus of control question approach could help identify individuals who may benefit from further discussion and investigation regarding their alcohol use. Having an external locus of control can be a risk factor for relapses or a warning sign of dependence (Johnson et al., 1991). Additionally, because DRIE questions are not asking about how much an individual is drinking, but rather their attitudes towards alcohol use, they help to minimize any inaccuracy that social desirability might motivate.
The DRIE is a forced choice measure with 25 questions. By having a forced choice format, there is less room for an individual to qualify their response or downplay their usage. They are being asked to select a choice which they believe most closely mirrors their behavior. The DRIE was initially assessed for construct validity using the Alcohol Use Inventory, a 147 multiple-choice questionnaire and demonstrated an alpha coefficient of internal consistency of .77 (Donovan & O’Leary, 1978).
As a 25- question measure is not easily administered in the primary care setting, this author sought to identify whether any individual questions on the DRIE could be reliable as a single-screener question to identify alcohol misuse or abuse. A study was conducted to confirm the DRIE as a reliable measure and then assess the 25-individual questions to determine if they would differentiate between those as high or low-risk.
In the current study, the DRIE was compared to the Alcohol Use Disorders Identification Test (AUDIT). A Phi Coefficient analysis was conducted to determine if there was a significant difference in the locus of control, as measured by the DRIE, between the individuals who were considered higher or lower risk determined by their AUDIT scores. Based on the results of this study, there is a small but significant relationship between individuals identified as being at risk for an SUD on both the AUDIT and the DRIE Φ = .18, p = .02, with an Area Under the Curve of .78, indicating that the possibility of random correlation is unlikely.
One research question in this study focused on whether any of the DRIE questions would show promise for use as an Alcohol Use Disorder screening tool. Of the 25 DRIE questions, 12 questions demonstrated statistical significance p>.05 in their ability to differentiate between at-risk and low-risk individuals, and five questions also demonstrated a large effect size, indicating the greatest potential promise as a screening tool as compared to the other DRIE questions. Results demonstrate promise for usefulness of an abbreviated version of the DRIE to be analyzed for use in a primary care environment.
As an initial exploratory study, the goal was to examine the possible predictive power of a locus of control question in identifying at-risk individuals. It is hoped that this research will spark a conversation regarding the current methods of alcohol screening and encourage exploration into other screening questions that may provide good predictive value and be easily administered in primary care environments.
References
Boniface, S., & Shelton, N. (2013). How is alcohol consumption affected if we account for under-reporting? A hypothetical scenario. The European Journal of Public Health, 23(6), 1076-1081.
Donovan, D. M., & O’Leary, M. R. (1978). The drinking-related locus of control scale. Reliability, factor structure and validity. Journal of Studies on Alcohol, 39(5), 759–784. https://doi.org/10.15288/jsa.1978.39.759
Johnson, E. E., Nora, R. M., Tan, B., & Bustos, N. (1991). Comparison of two locus of control scales in predicting relapse in an alcoholic population. Perceptual and Motor Skills, 72(1), 43-50.
McPherson, T. L., & Hersch, R. K. (2000). Brief substance use screening instruments for primary care settings: A review. Journal of Substance Abuse Treatment, 18(2), 193-202.
McNeely, J. & Hamilton, L. (2022). Screening for unhealthy alcohol and drug use in general medicine settings. Medical Clinics of North America, 106(1), 13–28. https://doi.org/10.1016/j.mcna.2021.08.002
Piazza, N. J., Martin, N., & Dildine, R. J. (2000). Screening instruments for alcohol and other drug problems. Journal of Mental Health Counseling, 22(3).
Stewart, S. H., & Connors, G. J. (2004). Screening for alcohol problems: What makes a test effective?. Alcohol Research & Health, 28(1), 5.
Yoast, R.A., Wilford, B.B. & Hayashi, S.W. (2008). Encouraging physicians to screen for and intervene in substance use disorders: Obstacles and strategies for change. Journal of Addictive Diseases, 27, 77-97. https://doi.org/10.1080/10550880802122687