My work is in behavioral health/detox. A screening tool we use every day, multiple times a day, is the CIWA-AR. This tool is designed to reduce treatment times for alcohol withdrawal and help guide treatment decisions during the detoxification phase (Soldi et al., 2020).
Selection Bias
All patients at my facility who come in for alcohol use disorder (AUD) are assessed utilizing the CIWA-AR. However, in some instances, patients come in for depression, bipolar, or other forms of mental illness and have AUD they are either not disclosing or we are not treating (Metcalfe, 2024). Furthermore, behavioral health professionals have specialized knowledge when using the tool daily. If a patient comes in with AUD but has co-morbidities that must be managed medically, the tool is then administered by a nurse on a medical floor who rarely, if ever, uses the tool. Some medical doctors can resist ordering the tool due to their unfamiliarity.
Furthermore, nurses may score patients differently since the tool is highly subjective, leading to under- or overmedication. In some instances, nurses will score patients higher than they are because they do not have an appropriate alternative PRN medication to give the patient. This can lead to unnecessary sedation or other adverse effects. Similarly, undermedication can lead to increased discomfort and potential complications.
To address this bias, it is imperative that our facility invests in continuous learning and improvement. This could involve behavioral health nurses administering the tool on medical floors or providing more extensive training to medical nurses and providers.
Length-Biased Sampling
Under the tool, the provider can prescribe a scheduled medication taper regardless of the CIWA-AR score or medication to be administered only based on the tool’s score. This is based upon the physician’s judgment and is subjective. Physicians may consider the amount and length of the AUD; however, patients receiving a scheduled taper will detox more efficiently and more quickly. To reduce bias, a standard should be implemented so that all patients being administered the tool receive a scheduled taper.
Lead Time Bias
Patients seeking help from their community mental health center or primary care office may not be identified as having AUD. This prolongs the disease and increases the risk of complications from detoxification once the patient is finally identified as having the disease. Thus, non-hospital care providers should screen all patients/clients under their care.
Overdiagnosis Bias
The example in our textbook of overenthusiasm leading to misdiagnosis could also occur with AUD (David D Celentano ScD MHS & Md, 2018). If those charged with assessing for AUD become overenthusiastic, patients could face unnecessary treatment and hospitalization (Kowalchuk et al., 2024). Not everyone who drinks alcohol has AUD. For this reason, practitioners should be highly trained and use the same set of objective criteria to diagnose AUD.
Volunteer Bias
Unfortunately, some patients abuse the system for various reasons, such as drug seeking or homelessness. These patients may not be appropriate for detox; however, they know what to say to receive treatment. Drug-seeking patients know how to answer the questions in the tool to receive the highest doses of medication. To mitigate this, a blood alcohol level (BAC) should be obtained from every patient seeking admission for AUD. A complete history should be conducted to determine if the patient is drug-seeking or desiring “three hots and a cot.”
References
David D Celentano ScD MHS & Md, M. S. (2018). Gordis epidemiology (6th ed.). Elsevier.
Kowalchuk, A., Ostovar-Kermani, T. G., Schaper, K., Grigoryan, L., Hirth, J. M., Mejia, M., Spooner, K. K., & Zoorob, R. J. (2024). Factors associated with intention to implement SBI and SUD treatment: A survey of primary care clinicians in Texas enrolled in an online course. BMC Primary Care, 25(1). https://doi.org/10.1186/s12875-024-02427-zLinks to an external site.
Metcalfe, B. (2024). Supporting people with co-occurring mental health issues, alcohol and drug use. Mental Health Practice, 27(2), 34–42. https://doi.org/10.7748/mhp.2024.e1675Links to an external site.
Soldi, M., Mauthner, O., Frei, I., & Hasemann, W. (2020). Experience of adult patients and professionals with a program for the prevention of alcohol withdrawal delirium in the acute care setting—a case study. Perspectives in Psychiatric Care, 57(2), 726–733. https://doi.org/10.1111/ppc.12604Links to an external site.
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