Associations between AUDIT-C and mortality vary by age and sex

Implementation of Opioid Safety Efforts: Influence of Academic Detailing on Adverse Outcomes Among Patients in the Veterans Health Administration

BACKGROUND

The Veterans Health Administration (VA) implemented academic detailing (AD) to support safer opioid prescribing and overdose prevention initiatives.

METHODS

Patient-level data were extracted monthly from VA's electronic health record to evaluate whether AD implementation was associated with changes in all-cause mortality, opioid poisoning inpatient admissions, and opioid poisoning emergency department (ED) visits in an observational cohort of patients with long-term opioid prescriptions (≥45-day supply of opioids 6 months prior to a given month with ≤15 days between prescriptions). A single-group interrupted time series analysis using segmented logistic regression for mortality and Poisson regression for counts of inpatient admissions and ED visits was used to identify whether the level and slope of these outcomes changed in response to AD implementation.

RESULTS

Among 955 376 unique patients (19 431 241 person-months), there were 53 369 deaths (29 025 pre-AD; 24 344 post-AD), 1927 opioid poisoning inpatient admissions (610 pre-AD; 1317 post-AD), and 408 opioid poisoning ED visits (207 pre-AD; 201 post-AD). Immediately after AD implementation, there was a 5.8% reduction in the odds of all-cause mortality (95% confidence interval [CI]: 0.897, 0.990). However, patients had a significantly increased incidence rate of inpatient admissions for opioid poisoning immediately after AD implementation (incidence rate ratio = 1.523; 95% CI: 1.118, 2.077). No significant differences in ED visits for opioid poisoning were observed.

CONCLUSIONS

AD was associated with decreased all-cause mortality but increased inpatient hospitalization for opioid poisoning among patients prescribed long-term opioids. Mechanisms via which AD's efforts influenced opioid-related outcomes should be explored.

Refractory hepatic hydrothorax is associated with increased mortality with death occurring at lower MELD-Na compared to cirrhosis and refractory ascites

BACKGROUND AND AIMS

Although refractory hepatic hydrothorax (RH) is a serious complication of cirrhosis, waitlisted patients do not receive standardized Model for End-stage Liver Disease (MELD) exemption because of inadequate evidence suggesting mortality above biochemical MELD. This study aimed to examine liver-related death (LRD) associated with RH compared to refractory ascites (RA).

APPROACH AND RESULTS

This was a retrospective cohort study of Veterans with cirrhosis. Eligibility criteria included participants with RH or RA, followed from their first therapeutic thoracentesis/second paracentesis until death or transplantation. The primary outcome was LRD with non-LRD or transplantation as competing risk. Of 2552 patients with cirrhosis who underwent therapeutic thoracentesis/paracentesis, 177 met criteria for RH and 422 for RA. RH was associated with a significantly higher risk of LRD (adjusted HR [aHR] 4.63, 95% CI 3.31-6.48) than RA overall and within all MELD-sodium (MELD-Na) strata (<10 aHR 4.08, 95% CI 2.30-7.24, 10-14.9 aHR 5.68, 95% CI 2.63-12.28, 15-24.9 aHR 4.14, 95% CI 2.34-7.34, ≥25 aHR 7.75, 95% CI 2.99-20.12). LRD was higher among participants requiring 1 (aHR 3.54, 95% CI 2.29-5.48), 2-3 (aHR 4.39, 95% CI 2.91-6.63), and ≥4 (aHR 7.89, 95% CI 4.82-12.93) thoracenteses relative to RA. Although participants with RH and RA had similar baseline MELD-Na, LRD occurred in RH versus RA at a lower MELD-Na (16.5 vs. 21.82, p =0.002) but higher MELD 3.0 (27.85 vs. 22.48, p <0.0001).

CONCLUSIONS

RH was associated with higher risk of LRD than RA at equivalent MELD-Na. By contrast, MELD 3.0 may better predict risk of LRD in RH.

Alcohol consumption and health-related quality of life in regional, rural and metropolitan Australia: analysis of cross-sectional data from the Community Health and Rural/Regional Medicine (CHARM) study

BACKGROUND

Relationships between alcohol consumption and health are complex and vary between countries, regions, and genders. Previous research in Australia has focused on estimating the effect of alcohol consumption on mortality. However, little is known about the relationships between alcohol consumption and health-related quality of life (QoL) in Australia. This study aimed to investigate the levels of alcohol intake and QoL in males and females in rural, regional and metropolitan areas of Australia.

METHOD

Participants (n = 1717 Australian adults) completed an online cross-sectional study. Males and females were compared on measures including the AUDIT-C and WHOQOL-BREF. Data were stratified into risk of alcohol use disorder (AUD) and associations were examined between alcohol consumption and QoL, adjusting for sociodemographic variables.

RESULTS

Males had higher alcohol consumption and were at greater risk of AUD than females (20% vs 8%). Relationships between alcohol consumption and QoL were positive or non-significant for low-moderate AUD risk categories and negative in the severe AUD risk category. Males in regional communities reported higher alcohol consumption (AUDIT-C score 6.6 vs 4.1, p < 0.01) than metropolitan areas. Regression analyses identified that after adjusting for sociodemographic variables, alcohol consumption was positively related to overall, environmental, and physical QoL and general health.

CONCLUSION

The results indicate that alcohol consumption is negatively related to QoL only in those with severe risk of AUD. Males in regional areas reported higher alcohol consumption than those in metropolitan areas. These results provide further information about relationships between alcohol intake and health in Australia that can help inform prevention, screening and delivery of interventions.

Association between clinical measures of unhealthy alcohol use and subsequent year hospital admissions in a primary care population

BACKGROUND

Screening for unhealthy alcohol use in primary care may help identify patients at risk for negative health outcomes.

AIMS

This study examined the associations between 1) screening with the AUDIT-C (alcohol consumption) and 2) an Alcohol Symptom Checklist (symptoms of alcohol use disorder) and subsequent-year hospitalizations.

METHODS

This retrospective cohort study was conducted in 29 primary care clinics in Washington State. Patients were screened in routine care (10/1/2016-2/1/2019) with the AUDIT-C (0-12) and administered the Alcohol Symptom Checklist (0-11) if they had AUDIT-C score ≥ 7. All-cause hospitalizations were measured within 1 year of the AUDIT-C and Alcohol Symptom Checklist. AUDIT-C and Alcohol Symptom Checklist scores were categorized based on previously used cut-points.

FINDINGS

Of 305,376 patients with AUDIT-Cs, 5.3% of patients were hospitalized in the following year. AUDIT-C scores had a J-shaped relationship with hospitalizations, with risk for all-cause hospitalizations higher for patients with the AUDIT-C scores 9-12 (12.1%; 95% CI: 10.6-13.7%, relative to a comparison group of those with AUDIT-C scores 1-2 (female)/1-3 (male) (3.7%; 95% CI: 3.6-3.8%), adjusted for socio-demographics. Patients with AUDIT-C ≥ 7 and Alcohol Symptom Checklist scores reflecting severe AUD were at increased risk of hospitalization (14.6%, 95% CI: 11.9-17.9%) relative to those with lower scores.

CONCLUSIONS

Higher AUDIT-C scores were associated with higher incidence of hospitalizations except among people with low-level drinking. Among patients with AUDIT-C ≥ 7, the Alcohol Symptom Checklist identified patients at increased risk of hospitalization. This study helps demonstrate the potential clinical utility of the AUDIT-C and Alcohol Symptom Checklist.

Spironolactone as a potential new pharmacotherapy for alcohol use disorder: convergent evidence from rodent and human studies

Evidence suggests that spironolactone, a nonselective mineralocorticoid receptor (MR) antagonist, modulates alcohol seeking and consumption. Therefore, spironolactone may represent a novel pharmacotherapy for alcohol use disorder (AUD). In this study, we tested the effects of spironolactone in a mouse model of alcohol drinking (drinking-in-the-dark) and in a rat model of alcohol dependence (vapor exposure). We also investigated the association between spironolactone receipt for at least 60 continuous days and change in self-reported alcohol consumption, using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), in a pharmacoepidemiologic cohort study in the largest integrated healthcare system in the US. Spironolactone dose-dependently reduced the intake of sweetened or unsweetened alcohol solutions in male and female mice. No effects of spironolactone were observed on drinking of a sweet solution without alcohol, food or water intake, motor coordination, alcohol-induced ataxia, or blood alcohol levels. Spironolactone dose-dependently reduced operant alcohol self-administration in dependent and nondependent male and female rats. In humans, a greater reduction in alcohol consumption was observed among those who received spironolactone, compared to propensity score-matched individuals who did not receive spironolactone. The largest effects were among those who reported hazardous/heavy episodic alcohol consumption at baseline (AUDIT-C ≥ 8) and those exposed to ≥ 50 mg/day of spironolactone. These convergent findings across rodent and human studies demonstrate that spironolactone reduces alcohol use and support the hypothesis that this medication may be further studied as a novel pharmacotherapy for AUD.

Naloxone Co-Dispensing with Opioids: a Cluster Randomized Pragmatic Trial

BACKGROUND

Although naloxone prevents opioid overdose deaths, few patients prescribed opioids receive naloxone, limiting its effectiveness in real-world settings. Barriers to naloxone prescribing include concerns that naloxone could increase risk behavior and limited time to provide necessary patient education.

OBJECTIVE

To determine whether pharmacy-based naloxone co-dispensing affected opioid risk behavior. Secondary objectives were to assess if co-dispensing increased naloxone acquisition, increased patient knowledge about naloxone administration, and affected opioid dose and other substance use.

DESIGN

Cluster randomized pragmatic trial of naloxone co-dispensing.

SETTING

Safety-net health system in Denver, Colorado, between 2017 and 2020.

PARTICIPANTS

Seven pharmacies were randomized. Pharmacy patients (N=768) receiving opioids were followed using automated data for 10 months. Pharmacy patients were also invited to complete surveys at baseline, 4 months, and 8 months; 325 survey participants were enrolled from November 15, 2017, to January 8, 2019.

INTERVENTION

Intervention pharmacies implemented workflows to co-dispense naloxone while usual care pharmacies provided usual services.

MAIN MEASURES

Survey instruments assessed opioid risk behavior; hazardous drinking; tobacco, cannabis, and other drug use; and knowledge. Naloxone dispensings and opioid dose were evaluated using pharmacy data among pharmacy patients and survey participants. Intention-to-treat analyses were conducted using generalized linear mixed models accounting for clustering at the pharmacy level.

KEY RESULTS

Opioid risk behavior did not differ by trial group (P=0.52; 8-month vs. baseline adjusted risk ratio [ARR] 1.07; 95% CI 0.78, 1.47). Compared with usual care pharmacies, naloxone dispensings were higher in intervention pharmacies (ARR 3.38; 95% CI 2.21, 5.15) and participant knowledge increased (P=0.02; 8-month vs. baseline adjusted mean difference 1.05; 95% CI 0.06, 2.04). There was no difference in other substance use by the trial group.

CONCLUSION

Co-dispensing naloxone with opioids effectively increased naloxone receipt and knowledge but did not increase self-reported risk behavior.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov ; Identifier: NCT03337100.

Rates and predictors of brief intervention for women veterans returning from recent wars: Examining gaps in service delivery for unhealthy alcohol use

BACKGROUND

Approximately one in four women veterans accessing the Department of Veterans Affairs (VA) engage in unhealthy alcohol use. There is substantial evidence for gender-sensitive screening (AUDIT-C = 3) and brief intervention (BI) to reduce risks associated with unhealthy alcohol use in women veterans; however, VA policies and incentives remain gender-neutral (AUDIT-C = 5). Women veterans who screen positive at lower-risk-level alcohol use (AUDIT-C = 3 or 4) may screen out and therefore not receive BI. This study aimed to examine gaps in implementation of BI practice for women veterans through identifying rates of BI at different alcohol risk levels (AUDIT-C = 3-4; =5-7; =8-12), and the role of alcohol risk level and other factors in predicting receipt of BI.

METHODS

From administrative data (2010-2016), we drew a sample of women veterans returning from recent wars who accessed outpatient and/or inpatient care. Of 869 women veterans, 284 screened positive for unhealthy alcohol use at or above a gender-sensitive cut-point (AUDIT-C ≥ 3). We used chart review methods to abstract variables from the medical record and then employed logistic regression comparing women veterans who received BI at varying alcohol risk levels to those who did not.

RESULTS

While almost 60% of the alcohol positive-risk sample received BI, among the subset of women veterans who screened positive for lower-risk alcohol use (57%; AUDIT-C = 3 or 4) only 34% received BI. Nurses in primary care programs were less likely to deliver BI than other types of clinicians (e.g., physicians, psychologists, social workers) in mental health programs; further, nurses in women's health programs were less likely to deliver BI than other types of clinicians in mixed-gender programs; Those women veterans with more medical problems were no more likely to receive BI than those with fewer medical problems.

CONCLUSIONS

Given that women veterans are a rapidly growing veteran population and a VA priority, underuse of BI for women veterans screening positive at a lower-risk level and those with more medical comorbidities requires attention, as do potential gaps in service delivery of BI in primary care and women's health programs. Women veterans health and well-being may be improved by tailoring screening for a younger cohort of women veterans at high-risk for, or with co-occurring disorders and then training providers in best practices for BI implementation.

Moderate alcohol use is associated with decreased brain volume in early middle age in both sexes

The aim was to examine cross-sectional association between moderate alcohol consumption and total brain volume in a cohort of participants in early middle-age, unconfounded by age-related neuronal change. 353 participants aged 39 to 45 years reported on their alcohol consumption using the AUDIT-C measure. Participants with alcohol abuse were excluded. Brain MRI was analyzed using a fully automated method. Brain volumes were adjusted by intracranial volume expressed as adjusted total brain volume (aTBV). AUDIT-C mean of 3.92 (SD 2.04) indicated moderate consumption. In a linear regression model, alcohol consumption was associated with smaller aTBV (B = - 0.258, p < .001). When sex and current smoking status were added to the model, the association remained significant. Stratified by sex, the association was seen in both males (B = - 0.258, p = 0.003) and females (B = - 0.214, p = 0.011). Adjusted for current smoking, the association remained in males (B = - 0.268, p = 0.003), but not in females. When alcohol consumption increased, total brain volume decreased by 0.2% per one AUDIT-C unit already at 39-45 years of age. Moderate alcohol use is associated with neuronal changes in both males and females suggesting health risks that should not be overlooked.

Associations between Gender, Alcohol Use and Negative Consequences among Korean College Students: A National Study

This study examines Korean college students’ rates and the severity of various negative consequences resulting from the frequency and quantity of alcohol consumption and the unique factors that are affecting this problem in the Korean context in comparison to other countries. It assesses how much gender, age and other associated respondent characteristics mediate alcohol use and the resulting negative consequences among the population. A stratified representative sample of 4803 valid student respondents attending 82 colleges participated in the alcohol consumption survey, of which 95% reported drinking in past 12 months. Drinking is measured by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screening tool. Based on this test, composite scores for each participant were computed and students were grouped into four risk groups: (a) nondrinkers, (b) light drinkers, (c) moderate drinkers and (d) heavy drinkers. Outcome measures include 21 validated items evaluating self-reported alcohol-related negative consequences. Rates of negative consequences are reported for each drinking risk group stratified by gender. Descriptive statistics, stepwise regression, multivariate linear regression and MANOVA tests were used to analyze the data. The study found that female respondents in the sample who consumed alcohol in the past 12 months drank 11.5 percent less than males (AUDIT-C score μ = 6.0 and 6.7, respectively), and there was a greater proportion of females (5.1 percent) who were nondrinkers than males (4.6 percent). Yet, when females drank, they experienced 11.8 percent more negative consequences on average than males (μ = 1.9 and 1.7, respectively). The study attempts to explain this apparent contradiction. The self-reported rates for many individual negative consequences also varied discernibly by gender. The study concludes with suggestions for how alcohol prevention on Korean college campuses would benefit from targeting females and males differently.

Associations Between Medical Conditions and Alcohol Consumption Levels in an Adult Primary Care Population

IMPORTANCE

Excessive alcohol consumption is associated with increased incidence of several medical conditions, but few nonveteran, population-based studies have assessed levels of alcohol use across medical conditions.

OBJECTIVE

To examine associations between medical conditions and alcohol consumption levels in a population-based sample of primary care patients using electronic health record data.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used separate multinomial logistic regression models to estimate adjusted associations between 26 medical conditions and alcohol consumption levels in a sample of 2 720 231 adult primary care patients screened for unhealthy drinking between January 1, 2014, and December 31, 2017, then only among those reporting alcohol use. The study was conducted at Kaiser Permanente Northern California, a large, integrated health care delivery system that incorporated alcohol screening into its adult primary care workflow. Data were analyzed from June 29, 2018, to February 7, 2020.

MAIN OUTCOMES AND MEASURES

The main outcome was level of alcohol use, classified as no reported use, low-risk use, exceeding daily limits only, exceeding weekly limits only, or exceeding daily and weekly limits, per National Institute on Alcohol Abuse and Alcoholism guidelines. Other measures included sociodemographic, body mass index, smoking, inpatient and emergency department use, and a dichotomous indicator for the presence of 26 medical conditions in the year prior to the alcohol screening identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM diagnosis codes.

RESULTS

Among the 2 720 231 included patients, 1 439 361 (52.9%) were female, 1 308 659 (48.1%) were white, and 883 276 (32.5%) were aged 18 to 34 years. Patients with any of the conditions (except injury or poisoning) had lower odds of drinking at low-risk and unhealthy levels relative to no reported use compared with those without the condition. Among 861 427 patients reporting alcohol use, patients with diabetes (odds ratio [OR], 1.11; 95% CI, 1.08-1.15), hypertension (OR, 1.11; 95% CI, 1.09-1.13), chronic obstructive pulmonary disease (COPD; OR, 1.16; 95% CI, 1.10-1.22), or injury or poisoning (OR, 1.06; 95% CI, 1.04-1.07) had higher odds of exceeding daily limits only; those with atrial fibrillation (OR, 1.12; 95% CI, 1.06-1.18), cancer (OR, 1.06; 95% CI, 1.03-1.10), COPD (OR, 1.15; 95% CI, 1.09-1.20), or hypertension (OR, 1.37; 95% CI, 1.34-1.40) had higher odds of exceeding weekly limits only; and those with COPD (OR, 1.15; 95% CI, 1.07-1.23), chronic liver disease (OR, 1.42; 95% CI, 1.32-1.53), or hypertension (OR, 1.48; 95% CI, 1.44-1.52) had higher odds of exceeding both daily and weekly limits.

CONCLUSIONS AND RELEVANCE

Findings suggest that patients with certain medical conditions are more likely to have elevated levels of alcohol use. Health systems and clinicians may want to consider approaches to help targeted patient subgroups limit unhealthy alcohol use and reduce health risks.

Short-term risk of suicide attempt associated with patterns of patient-reported alcohol use determined by routine AUDIT-C among adults receiving mental healthcare

OBJECTIVE

To evaluate the association between alcohol use routinely reported during outpatient mental healthcare visits and short-term risk of subsequent suicide attempt.

METHODS

Using a longitudinal retrospective-cohort design, electronic health records identified adult outpatient visits to a mental health provider (1/1/2010-6/30/2015) at Kaiser Permanente Washington with a documented Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]. Suicide attempts within 90 days of AUDIT-C documentation were defined using death certificate cause-of-death and diagnosis codes (non-lethal). Visit-level analyses used generalized estimating equations to account for correlation between multiple AUDIT-Cs for individuals. Separate models evaluated the association between (1) level of consumption and (2) frequency of heavy drinking episodes and suicide attempts, adjusted for visit year, demographics, depressive symptom, and suicidal ideation.

RESULTS

Of 59,382 patient visits, 0.62% (N = 371) were followed by a suicide attempt within 90 days. Patients reporting high-level alcohol use were 1.77 times (95% CI, 1.22-2.57) more likely to attempt suicide than those reporting low-level use. Patients reporting daily or almost daily heavy drinking episodes were 2.33 times (95% CI, 1.38-3.93) more likely to attempt suicide than those reporting none.

CONCLUSIONS AND RELEVANCE

The AUDIT-C is a valuable tool for assessing patterns of patient-reported alcohol use associated with subsequent suicide attempt.

Association Between Alcohol Use and Angina Symptoms Among Outpatients From the Veterans Health Administration

BACKGROUND

Alcohol use is associated with angina incidence, but associations between alcohol use and experience of angina among patients with coronary artery disease (CAD) have not been described.

METHODS

Outpatients with CAD from 7 clinics in the Veterans Health Administration were surveyed; alcohol use was measured using the validated Alcohol Use Disorders Identification Test-Consumption scores categorized into 6 groups: nondrinking, low-risk drinking, and mild, moderate, severe, and very severe unhealthy alcohol use. Three domains of self-reported angina symptoms (frequency, stability, and physical function) were measured with the Seattle Angina Questionnaire. Linear regression models evaluated associations between alcohol use groups and angina symptoms. Models were adjusted first for age and then additionally for smoking, comorbidities, and depression.

RESULTS

Patients (n = 8303) had a mean age of 66 years. In age-adjusted analyses, a U-shaped association was observed between alcohol use groups and all angina outcomes, with patients in nondrinking and severe unhealthy alcohol groups reporting the greatest angina symptoms and lowest functioning. After full adjustment, no clinically important and few statistically important differences were observed across alcohol use in angina stability or frequency. Patients in the nondrinking group had statistically greater functional limitation from angina than those in all groups of unhealthy alcohol use, though differences were small. Patients in all groups of unhealthy alcohol use did not differ significantly from those with low-risk drinking.

CONCLUSIONS

Alcohol use was associated with some small statistically but no clinically important differences in angina symptoms among patients with CAD. This cross-sectional study does not support a protective effect of low-level drinking on self-reported angina.

HIV Disease Severity Is Sensitive to Temporal Changes in Alcohol Use: A National Study of VA Patients With HIV

BACKGROUND

Alcohol use influences HIV disease severity through multiple mechanisms. Whether HIV disease severity is sensitive to changes in alcohol use among people with HIV (PWH) is understudied.

SETTING

National Veterans Health Administration.

METHODS

Pairs of AUDIT-C screens within 9-15 months (February 1, 2008-September 30, 2014) were identified among PWH from the Veterans Aging Cohort Study (VACS). Initial and follow-up VACS Index 2.0 pairs obtained 0-270 days after initial and follow-up AUDIT-Cs, respectively, determined change in VACS Index 2.0, a composite HIV severity measure. Change in VACS Index 2.0 was regressed on AUDIT-C change scores (-12 to +12) adjusted for demographics, initial VACS Index 2.0, and days between VACS Index measures.

RESULTS

Among 23,297 PWH (76,202 observations), most had no (51%) or low-level (38%) alcohol use initially. Most (54%) had no subsequent change; 21% increased and 24% decreased drinking. Initial VACS Index 2.0 scores ranged from 0 to 134, change scores ranged from -65 to +73, with average improvement of 0.76 points (SD 9.48). AUDIT-C change was associated with VACS Index 2.0 change (P < 0.001). Among those with stable alcohol use (AUDIT-C change ≤ │1│ point), VACS Index 2.0 improvements ranged 0.36-0.60 points. For those with maximum AUDIT-C increase (change from 0 to 12), VACS Index 2.0 worsened 3.74 points (95% CI: -4.71 to -2.78); for those with maximum AUDIT-C decrease (change from 12 to 0), VACS Index 2.0 changed minimally [-0.60 (95% CI: -1.43 to 0.23)].

CONCLUSIONS

In this national sample, improvement in HIV severity was generally greatest among those with stable alcohol use (primarily those with no use).

The prevalence and factors associated with smoking among lesbian and bisexual women: Analysis of the Australian National Drug Strategy Household Survey

BACKGROUND

In many countries, sexual minority women smoke at higher rates than their heterosexual counterparts. Analyses tend to combine lesbian and bisexual women, preventing an understanding of relevant factors associated with smoking for each group. This analysis used a representative sample of the Australian population to compare tobacco use between heterosexual, lesbian and bisexual women, and examine factors associated with smoking among these groups.

METHODS

In a secondary analysis of data from the National Drug Strategy Household Survey (N = 23,855), descriptive statistics were produced for heterosexual (n = 11,776), lesbian (n = 135) and bisexual (n = 167) women. Multivariate logistic regression modelling was undertaken to assess which factors were associated with current smoking among the different groups.

RESULTS

Compared to heterosexual women, lesbian and bisexual women were more likely to be current smokers (OR 2.9(1.8,4.5) and OR 3.6(2.4, 5.4) respectively). Employment, income and psychological distress were significant factors associated with smoking for lesbian women. Recent illicit drug use was the only significant factor associated with smoking for bisexual women.

CONCLUSIONS

We need to better understand the psychological, social and cultural factors that influence initiation, and sustain smoking among lesbian and bisexual women. Our findings demonstrate that sexual minority women in Australia warrant specific policy attention in a national framework.

Level of Alcohol Use Associated with HIV Care Continuum Targets in a National U.S. Sample of Persons Living with HIV Receiving Healthcare

We evaluated associations between levels of alcohol use and HIV care continuum components using national Veterans Aging Cohort Study data for all patients with HIV and AUDIT-C screening (2/1/2008-9/30/2014). Poisson regression models evaluated associations between alcohol use levels (non-drinking, low-, medium-, high-, and very high-level drinking) and: (1) engagement with care (documented CD4 cells/µl or viral load copies/ml labs), (2) ART treatment (≥ 1 prescription), and (3) viral suppression (HIV RNA < 500 copies/ml) within one year. Among 33,224 patients, alcohol use level was inversely associated with all care continuum outcomes (all p < 0.001). Adjusted prevalence of care engagement ranged from 77.8% (95% CI 77.1-78.4%) for non-drinking to 69.1% (66.6-71.6%) for high-level drinking. The corresponding range for ART treatment was 74.0% (73.3-74.7%) to 60.1% (57.3-62.9%) and for viral suppression was 57.3% (56.5-58.1%) to 38.3% (35.6-41.1%). Greater alcohol use is associated with suboptimal HIV treatment across the HIV care continuum.

Attitudes and Perceived Social Norms toward Drug Use among Gay and Bisexual Men in Australia

BACKGROUND

Gay and bisexual men (GBM) report distinctive patterns and contexts of drug use, yet little has been published about their attitudes toward drug use.

OBJECTIVES

We developed measures of attitudes and perceived social norms toward drug use, and examined covariates of more accepting attitudes and norms among GBM in Australia.

METHODS

We analyzed baseline data from the Following Lives Undergoing Change (Flux) study. Flux is an online prospective observational study of drug use among Australian GBM. We used principal components factor analysis to generate two attitudinal scales assessing "drug use for social and sexual enhancement" and "perceptions of drug risk." A third perceived social norms scale examined "acceptability of drug use among gay friends."

RESULTS

Among 2,112 participants, 61% reported illicit drug use in the preceding six months. Stronger endorsement of drug use for social and sexual engagement and lower perceptions of drug risk were found among men who were more socially engaged with other gay men and reported regular drug use and drug use for sex. In multivariate analyses, all three scales were associated with recent drug use (any use in the previous six months), but only the drug use for social and sexual enhancement scale was associated with regular (at least monthly) use.

CONCLUSIONS

Drug use and sex are difficult to disentangle for some GBM, and health services and policies could benefit from a better understanding of attitudinal and normative factors associated with drug use in gay social networks, while recognizing the role of pleasure in substance use.

Typology of new psychoactive substance use among the general Australian population

AIM

The aim of this study was to examine the typology of Australian illicit drug consumers to determine whether those who use new psychoactive substances (NPS) differ from those using other illicit substances.

METHODS

Data were from the 2013 National Drug Strategy Household Survey, a representative population study; analyses were limited to participants reporting past year illicit drug use (including NPS; n = 3309). Latent class analysis identified groups based on past year substance use, and a weighted multivariable, multinomial regression model was used to examine characteristics associated with group membership.

RESULTS

Six consumer typologies were identified: cannabis consumers (46%), pharmaceutical consumers (21%), ecstasy and cocaine consumers (19%), amphetamine and cannabis consumers (7%), polysubstance consumers (6%), and inhalant consumers (2%). Sixteen participants (total sample: 0.07%; NPS consumers: 5.7%) reported exclusive NPS use. Synthetic cannabinoid receptor agonist use was highest among amphetamine and cannabis consumers and polysubstance consumers; other NPS use was highest among polysubstance consumers. Polysubstance consumers were younger than all other groups, and more likely to engage in dangerous activities while under the influence of substances, inject drugs and report hazardous alcohol consumption. Amphetamine and cannabis consumers were more likely to report trouble ceasing their drug use.

CONCLUSION

We found no distinct profile of NPS-only consumers; however, NPS use was a marker for more problematic patterns of use. Our findings suggest that specialised NPS interventions or harm reduction messages may not be required in the Australian context; rather, they could be based upon existing responses to drug use.

Alcohol Use Disorders Identification Test (AUDIT) and mortality risk: a systematic review and meta-analysis

Background

We summarise the evidence for an association between screening scores from the Alcohol Use Disorders Identification Test (AUDIT) and all-cause mortality.

Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, prospective cohort studies reporting all-cause mortality risk by AUDIT scores (complete AUDIT-10 or AUDIT-C) were identified through MEDLINE, Embase, PubMed and Web of Science up to September 2016. Risk estimates were pooled using random effects meta-analyses.

Results

Seven observational studies with 18 920 observed deaths among 309 991 participants were identified. At-risk drinking (ie, hazardous/harmful consumption, AUDIT-10 ≥8 and AUDIT-C ≥4) was associated with elevated mortality risk after 2–10 years of follow-up (pooled relative risk (RR)=1.24, 95% CI 1.12 to 1.37) compared with moderate drinking (AUDIT-10=1–7, AUDIT-C=1–3). Compared to past year abstainers (AUDIT=0), moderate drinkers had a lower mortality risk (RR=0.75, 95% CI 0.71 to 0.79) in US Veterans and a similar mortality risk (RR=0.99, 95% CI 0.72 to 1.38) in population-based studies. Most data came from studies among Veterans using the short AUDIT-C in men and showed a dose–response relationship (RR=1.04, 95% CI 1.04 to 1.05 for each AUDIT-C score among drinkers). Data for women and young adults were scarce.

Conclusion

AUDIT screening scores were associated with mortality risk. The association was differential depending on the population examined, which may be related to prevalence of former drinkers among current abstainers. Due to heterogeneity between studies and the small number of populations examined, generalisability may be limited.

Influence of a targeted performance measure for brief intervention on gender differences in receipt of brief intervention among patients with unhealthy alcohol use in the Veterans Health Administration

AIMS

Women are less likely than men to receive brief intervention (BI) for unhealthy alcohol use. In 2007, the U.S. Veterans Health Administration (VA) used a national performance measure to implement BI. Although AUDIT-C scores ≥3 for women and ≥4 for men optimize sensitivity and specificity for identifying unhealthy alcohol use, VA's performance measure required BI only among a targeted subgroup defined by a non-gender-specific score threshold (AUDIT-C ≥5). This may have influenced gender differences in receipt of BI among those optimally eligible for BI. Therefore, we evaluate differences in proportions of women and men offered BI before and after BI implementation.

METHODS

National secondary chart review data (7/06-6/10) identified all outpatients with unhealthy alcohol use for whom BI would be indicated (AUDIT-C ≥3 women, ≥4 men). Logistic regression, including a time-by-gender interaction, estimated the prevalence and 95% confidence interval (CI) of BI for women and men pre- and post-implementation.

FINDINGS

Among patients optimally eligible for BI (n=51,272, 8206 women and 43,066 men), the prevalence of BI increased more steeply for men than women after implementation (interaction p-value <0.0001). Pre-implementation rates of BI were 21% (95% CI, 18-24) for women and 26% (95% CI, 24-29) for men, and post-implementation rates were 32% (95% CI, 30-34) for women and 47% (95% CI, 45-49) for men.

CONCLUSIONS

Healthcare systems implementing BI with performance measures may wish to consider that specifying a single alcohol screening threshold for men and women may increase gender differences in receipt of BI among patients likely to benefit.

Psychosocial stressors and alcohol use, severity, and treatment receipt across human immunodeficiency virus (HIV) status in a nationally representative sample of US residents

BACKGROUND

Human immunodeficiency virus (HIV) is stigmatized and disproportionately impacts vulnerable populations. Thus, people living with HIV (PLWH) may have greater exposure to psychosocial stressors than those without HIV. Exposure to psychosocial stressors may increase alcohol use and serve as barriers to alcohol treatment receipt. The authors evaluate whether psychosocial stressors and alcohol use, symptom severity, and treatment receipt vary across HIV status in a general population sample of US residents and assess whether psychosocial stressors mediate identified associations.

METHODS

Data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were used to assess associations between HIV status and psychosocial stressors (perceived stress, alcohol-related stigma, and perceived discrimination based on race/ethnicity, sexual orientation, or sex) and alcohol-related outcomes (any use, heavy drinking, symptom severity, and treatment receipt). For each outcome, regression models were fit and iteratively adjusted for sociodemographic characteristics and comorbidities. Indirect effects of HIV on alcohol-related outcomes through stressors were estimated to assess mediation when main effects were significant.

RESULTS

Among 34,653 NESARC Wave 2 respondents, 161 were PLWH. PLWH were more likely than those without HIV to experience discrimination and had higher levels of perceived stress than those without HIV (P values <.05), but the 2 groups did not differ regarding alcohol-related stigma. PLWH were less likely to use alcohol and had similar rates of heavy drinking relative to participants without HIV, but alcohol symptom severity and treatment receipt were greater among PLWH. Perceived stress but not discrimination mediated associations.

CONCLUSIONS

Findings from this first study of variation in psychosocial stressors and alcohol use, severity, and treatment receipt across HIV status further highlight PLWH as a population that is particularly vulnerable to experiences of psychosocial stress and certain adverse alcohol-related outcomes. Future longitudinal research is needed in a larger sample of PLWH to identify intervention targets.

Alcohol misuse, risky sexual behaviors, and HIV or syphilis infections among Chinese men who have sex with men

BACKGROUND

Few studies have employed standardized alcohol misuse measures to assess relationships with sexual risk and HIV/syphilis infections among Chinese men who have sex with men (MSM).

METHODS

We conducted a cross-sectional study among MSM in Beijing during 2013-2014. An interviewer-administered survey was conducted to collect data on sociodemographics, high-risk behaviors, and alcohol use/misuse patterns (hazardous/binge drinking and risk of alcohol dependence) in the past 3 months using Alcohol Use Disorder Identification Test-Consumption (AUDIT-C). We defined AUDIT-C score ≥4 as recent hazardous drinkers, and drinking ≥6 standard drinks on one occasion as recent binge drinkers.

RESULTS

Of 3588 participants, 14.4% reported hazardous drinking, 16.8% reported binge drinking. Hazardous and binge drinking are both associated with these factors (p<0.05): older age, being migrants, living longer in Beijing, township/village origin, being employed, higher income, self-perceived low/no HIV risk, and sex-finding via non-Internet venues. Hazardous (vs non-hazardous) or binge (vs. non-binge) drinkers were more likely to use illicit drugs, use alcohol before sex, have multiple partnerships, pay for sex, and have condomless insertive anal intercourse. MSM who reported binge (AOR, 1.34, 95% CI, 1.02-1.77) or hazardous (AOR, 1.36, 95% CI, 1.02-1.82) drinking were more likely to be HIV-infected. MSM at high risk of current alcohol dependence (AUDIT-C ≥8) were more likely to be HIV- (AOR, 2.37, 95% CI, 1.39-4.04) or syphilis-infected (AOR, 1.96, 95% CI, 1.01-3.86).

CONCLUSIONS

Recent alcohol misuse was associated with increased sexual and HIV/syphilis risks among Chinese MSM, emphasizing the needs of implementing alcohol risk reduction programs in this population.

Predictive validity of clinical AUDIT-C alcohol screening scores and changes in scores for three objective alcohol-related outcomes in a Veterans Affairs population

AIMS

To evaluate the association between Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) alcohol screening scores, collected as part of routine clinical care, and three outcomes in the following year (Aim 1), and the association between changes in AUDIT-C risk group at 1-year follow-up and the same outcomes in the subsequent year (Aim 2).

DESIGN

Cohort study.

SETTING

Twenty-four US Veterans Affairs (VA) healthcare systems (2004-07), before systematic implementation of brief intervention.

PARTICIPANTS

A total of 486 115 out-patients with AUDIT-Cs documented in their electronic health records (EHRs) on two occasions ≥ 12 months apart ('baseline' and 'follow-up').

MEASUREMENTS

Independent measures were baseline AUDIT-C scores and change in standard AUDIT-C risk groups (no use, low-risk use and mild, moderate, severe misuse) from baseline to follow-up. Outcome measures were (1) high-density lipoprotein cholesterol (HDL), (2) alcohol-related gastrointestinal hospitalizations ('GI hospitalizations') and (3) physical trauma, each in the years after baseline and follow-up.

FINDINGS

Baseline AUDIT-C scores had a positive association with outcomes in the following year. Across AUDIT-C scores 0-12, mean HDL ranged from 41.4 [95% confidence interval (CI) = 41.3-41.5] to 53.5 (95% CI = 51.4-55.6) mg/l, and probabilities of GI hospitalizations from 0.49% (95% CI = 0.48-0.51%) to 1.8% (95% CI = 1.3-2.3%) and trauma from 3.0% (95% CI = 2.95-3.06%) to 6.0% (95% CI = 5.2-6.8%). At follow-up, patients who increased to moderate or severe alcohol misuse had consistently higher mean HDL and probabilities of subsequent GI hospitalizations or trauma compared with those who did not (P-values all < 0.05). For example, among those with baseline low-risk use, in those with persistent low-risk use versus severe misuse at follow-up, the probabilities of subsequent trauma were 2.65% (95% CI = 2.54-2.75%) versus 5.15% (95% CI = 3.86-6.45%), respectively. However, for patients who decreased to lower AUDIT-C risk groups at follow-up, findings were inconsistent across outcomes, with only mean HDL decreasing in most groups that decreased use (P-values all < 0.05).

CONCLUSIONS

When AUDIT-C screening is conducted in clinical settings, baseline AUDIT-C scores and score increases to moderate-severe alcohol misuse at follow-up screening appear to have predictive validity for HDL cholesterol, alcohol-related gastrointestinal hospitalizations and physical trauma. Decreasing AUDIT-C scores collected in clinical settings appear to have predictive validity for only HDL.

Risk of mortality and physiologic injury evident with lower alcohol exposure among HIV infected compared with uninfected men

BACKGROUND

HIV infected (HIV+) individuals may be more susceptible to alcohol-related harm than uninfected individuals.

METHODS

We analyzed data on HIV+ and uninfected individuals in the Veterans Aging Cohort Study (VACS) with an Alcohol Use Disorders Identification Test-Consumption AUDIT-C score from 2008 to 2012. We used Cox proportional hazards models to examine the association between alcohol exposure and mortality through July, 2014; and linear regression models to assess the association between alcohol exposure and physiologic injury based on VACS Index Scores. Models were adjusted for age, race/ethnicity, smoking, and hepatitis C infection.

RESULTS

The sample included 18,145 HIV+ and 42,228 uninfected individuals. Among HIV+ individuals, 76% had undetectable HIV-1 RNA (<500 copies/ml). The threshold for an association of alcohol use with mortality and physiologic injury differed by HIV status. Among HIV+ individuals, AUDIT-C score ≥4 (hazard ratio [HR] 1.25, 95% CI 1.09-1.44) and ≥30 drinks per month (HR, 1.30, 95% CI 1.14-1.50) were associated with increased risk of mortality. Among uninfected individuals, AUDIT-C score ≥5 (HR, 1.19, 95% CI 1.07-1.32) and ≥70 drinks per month (HR 1.13, 95% CI 1.00-1.28) were associated with increased risk. Similarly, AUDIT-C threshold scores of 5-7 were associated with physiologic injury among HIV+ individuals (beta 0.47, 95% CI 0.22, 0.73) and a score of 8 or more was associated with injury in uninfected (beta 0.29, 95% CI 0.16, 0.42) individuals.

CONCLUSIONS

Despite antiretroviral therapy, HIV+ individuals experienced increased mortality and physiologic injury at lower levels of alcohol use compared with uninfected individuals. Alcohol consumption limits should be lower among HIV+ individuals.

Alcohol Consumption Levels and All-Cause Mortality Among Women Veterans and Non-Veterans Enrolled in the Women's Health Initiative

PURPOSE

To address research gaps regarding women Veterans' alcohol consumption and mortality risk as compared to non-Veterans, the current study evaluated whether alcohol consumption amounts differed between women Veterans and non-Veterans, whether Veterans and non-Veterans within alcohol consumption groups differed on all-cause mortality, and whether Veteran status modified the association between alcohol consumption and all-cause mortality.

DESIGN AND METHODS

Six alcohol consumption groups were created using baseline data from the Women's Health Initiative Program (N = 145,521): lifelong abstainers, former drinkers, less than 1 drink/week (infrequent drinkers), 1-7 drinks/week (moderate drinkers), 8-14 drinks/week (moderately heavy drinkers), and 15 or more drinks/week (heavy drinkers). The proportions of Veteran and non-Veteran women within each alcohol consumption category were compared. Mortality rates within each alcohol consumption category were compared by Veteran status. Cox proportional hazard models, including a multiplicative interaction term for Veteran status, were fit to estimate adjusted mortality hazard (rate) ratios for each alcohol consumption category relative to a reference group of either lifelong abstainers or moderate drinkers.

RESULTS

Women Veterans were less likely to be lifelong abstainers than non-Veterans. Women Veterans who were former or moderate drinkers had higher age-adjusted mortality rates than did non-Veterans within these alcohol consumption categories. In the fully adjusted multivariate models, Veteran status did not modify the association between alcohol consumption category and mortality with either lifelong abstainers or moderate drinkers as referents.

IMPLICATIONS

The results suggest that healthcare providers may counsel Veteran and non-Veteran women in similar ways regarding safe and less safe levels of alcohol consumption.

Sexual identity and prevalence of alcohol and other drug use among Australians in the general population

BACKGROUND

International research assessing differences in the prevalence of alcohol and other drug (AOD) use among Lesbian Gay Bisexual and Transgender (LGBTI) and heterosexual populations shows elevated prevalence rates of substance use among LGBTI people. To date no research has been published investigating these differences at a population level among both men and women in Australia.

METHODS

The 2013 National Drug Strategy Household Survey, a multistage stratified population sample collecting data on AOD use in the Australian population over 14 years of age, was analysed for differences between gay and bisexual (GB) men and lesbian/gay and bisexual (LGB) women and their heterosexual counterparts in: (1) the prevalence of lifetime and past year tobacco and AOD use; (2) age of initiation of tobacco and AOD use; and (3) frequency of alcohol and cannabis use, and history of AOD treatment.

RESULTS

There were elevated rates of past year cannabis (22.4%), ecstasy (11.8%) and methamphetamine (9.7%) use among GB men compared to heterosexual men (12.4%, 2.9% and 2.5%). LGB women also reported elevated rates of past year use (tobacco - 23.7%; cannabis - 24.6%) compared to heterosexual women (10.6% and 7.1%). LGB women initiated tobacco (15.2 years) and alcohol (15.5 years) at an earlier age than heterosexual women (16.6 and 17.7 years), and were significantly more likely to report daily alcohol consumption (OR 3.2, 95% CI: 2.1, 5.1), and weekly or more frequent cannabis use (OR 1.7, 95%CI: 1.1, 3.1).

CONCLUSIONS

These findings are indicative of the need for more responsive and targeted AOD harm reduction and treatment services for LGBTI communities in Australia. Of concern is the elevated risk among LGB women for earlier initiation of substance use, and the development of problematic consumption patterns. Further research, investigating the risk and protective factors for AOD use among LGB women is warranted.

Factors Affecting Women's Disclosure of Alcohol Misuse in Primary Care: A Qualitative Study with U.S. Military Veterans

BACKGROUND

One in five women veterans screens positive for alcohol misuse. Women may be less likely than men to disclose alcohol use to a primary care provider (PCP), resulting in women being less likely to receive effective interventions. We sought to qualitatively examine factors that may affect women veterans' willingness to disclose alcohol use to a PCP.

METHODS

Between October 2012 and May 2013, in-depth interviews were conducted with 30 women veterans at two Department of Veterans Affairs (VA) medical facilities. Qualitative data analyses identified common themes representing factors that influence women's decision to disclose alcohol use to a PCP.

FINDINGS

Nine themes were endorsed by women veterans as influencing their willingness to disclose alcohol use to their PCP. Themes included provider behaviors perceived as encouraging or discouraging disclosure of alcohol misuse, perceived positive relationship with provider, negative emotions such as concerns about being judged or labeled an "alcoholic," health concerns about drinking, non-health-related concerns about drinking, self-appraisal of drinking behavior, social support, and clinic factors.

CONCLUSIONS

Our findings demonstrate the importance of social relationships, comfort with one's provider, and education on the potential harms (especially health related) associated with alcohol in encouraging disclosure of alcohol use in women veterans. Our results also support VA national health care efforts, including the provision of brief alcohol counseling and the use of primary care clinics specializing in the care of women veterans.

Inconsistency in reporting abstention and heavy drinking frequency: associations with sex and socioeconomic status, and potential impacts

AIMS

To describe inconsistencies in reporting past-year drinking status and heavy drinking occasions (HDOs) on single questions from two different instruments, and to identify associated characteristics and impacts.

METHODS

We compared computer-presented Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) with categorical response options, and mental health interview (MHI) with open-ended consumption questions, completed on the same day. Participants were 464 men and 459 women aged 38 (91.7% of surviving birth cohort members). Differences in dichotomous single-item measures of abstention and HDO frequency, associations of inconsistent reporting with sex, socioeconomic status (SES) and survey order, and impacts of instrument choice on associations of alcohol with sex and SES were examined.

RESULTS

The AUDIT-C drinking frequency question estimated higher past-year abstention prevalence (AUDIT = 7.6%, MHI = 5.4%), with one-third of AUDIT-C abstainers being MHI drinkers. Only AUDIT-C produced significant sex differences in abstainer prevalence. Inconsistencies in HDO classifications were bidirectional, but with fewer HDOs reported on the MHI than AUDIT-C question. Lower SES was associated with inconsistency in abstention and weekly+ HDOs. Abstention and higher HDO frequency were associated with lower SES overall, but sex-specific associations differed by instrument.

CONCLUSIONS

In this context, data collection method affected findings, with inconsistencies in abstention reports having most impact. Future studies should: (a) confirm self-reported abstention; (b) consider piloting data collection methods in target populations; (c) expect impacts of sex and SES on measurements and analyses.

Alcohol and drug misuse, abuse, and dependence in women veterans

We conducted a systematic literature review on substance misuse, abuse, and dependence in women veterans, including National Guard/reserve members. We identified 837 articles published between 1980 and 2013. Of 56 included studies, 32 reported rates of alcohol misuse, binge drinking, or other unhealthy alcohol use not meeting diagnostic criteria for abuse or dependence, and 33 reported rates of drug misuse or diagnosed alcohol or drug use disorders. Rates ranged from 4% to 37% for alcohol misuse and from 7% to 25% for binge drinking; among Veterans Health Administration (VA) health-care system outpatients, rates ranged from 3% to 16% for substance use disorder. Studies comparing women veterans and civilians reported no clear differences in binge or heavy drinking. Substance misuse rates were generally lower among women veterans than men veterans. Substance misuse was associated with higher rates of trauma, psychiatric and medical conditions, and increased mortality and suicide rates. Most studies included only VA patients, and many used only VA medical record data; therefore, the reported substance misuse rates likely do not reflect true prevalence. Rates also varied by assessment method, source of data, and the subgroups studied. Further efforts to develop epidemiologically valid prevalence estimates are needed to capture the true health burden of substance misuse in women veterans, particularly those not using VA care.

Alcohol use among a community-based sample of gay men: Correlates of high-risk use and implications for service provision

INTRODUCTION AND AIMS

International research has shown that gay, bisexual and other homosexually active men (hereafter 'gay men') report disproportionately higher rates of risky alcohol use and associated problems compared with heterosexual men. However, little is known about alcohol use among this population in Australia. This study aimed to examine rates of risky alcohol use among a community-based sample of gay men in Sydney and characteristics of men reporting high-risk alcohol use and adverse consequences.

DESIGN AND METHODS

A cross-sectional survey of gay men was conducted in Sydney in August 2013 as part of the ongoing Gay Community Periodic Surveys (n = 1546 eligible respondents). The Alcohol Use Disorders Identification Test-Consumption questions were used to assess alcohol use in the previous 12 months.

RESULTS

Nine percent of respondents were categorised as abstinent from alcohol, 33% as low-risk drinkers, 42% as moderate-risk drinkers and 16% as high-risk drinkers. In separate multivariate logistic regression analyses, high-risk drinking and reporting ≥4 adverse alcohol consequences were associated with younger age, being Australian-born, recruitment from licensed premises and having met men for sex at gay bars and dance parties. Fifty-eight percent of high-risk drinkers reported a desire to reduce their alcohol use.

DISCUSSION AND CONCLUSIONS

In this community-based sample of gay men, we found high levels of moderate- to high-risk alcohol use. The results suggest that gay men should be a priority population for health promotion campaigns and treatment services.

National prevalence and correlates of alcohol misuse in women veterans

Our goal was to estimate the prevalence and correlates of alcohol misuse in women veterans and to assess the associations between alcohol misuse and mental health (MH) care utilization in a group comprising both Veterans Health Administration (VA) healthcare system users and non-users. We assessed alcohol misuse using survey-based AUDIT-C scores. The prevalence of alcohol misuse was 27% in VA users and 32% in non-users. Prevalence rates were higher for VA users who were younger, served in OEF/OIF, or had combat exposure and for VA non-users who screened positive for posttraumatic stress disorder or sexual assault in the military. In contrast to VA users, VA non-users with alcohol misuse had a low prevalence of past-year MH care despite having indications of MH care need. Our results on alcohol misuse prevalence, its correlates, and its association with MH care may aid program planning and resource allocation in VA and non-VA settings.

Clinical management of alcohol use disorders in the neurology clinic

Alcohol misuse adversely affects health outcomes, but alcohol misuse and alcohol use disorders (AUDs) are often ignored by healthcare providers in primary and specialty ambulatory care clinics. Data show that early identification and brief intervention for alcohol misuse in these settings can effectively reduce alcohol consumption and its medical sequelae. The aim of this chapter is to review the epidemiology of problematic alcohol use in ambulatory care settings, the diagnostic criteria for AUDs, the approach called SBIRT (screening, brief intervention and referral to treatment) as a model program to target alcohol misuse in everyday clinical practice, when and how to refer patients to resources beyond the clinic for their alcohol use problems, and the medical illnesses associated with AUDs.

Inconsistencies between alcohol screening results based on AUDIT-C scores and reported drinking on the AUDIT-C questions: prevalence in two US national samples

Background

The AUDIT-C is an extensively validated screen for unhealthy alcohol use (i.e. drinking above recommended limits or alcohol use disorder), which consists of three questions about alcohol consumption. AUDIT-C scores ≥4 points for men and ≥3 for women are considered positive screens based on US validation studies that compared the AUDIT-C to “gold standard” measures of unhealthy alcohol use from independent, detailed interviews. However, results of screening—positive or negative based on AUDIT-C scores—can be inconsistent with reported drinking on the AUDIT-C questions. For example, individuals can screen positive based on the AUDIT-C score while reporting drinking below US recommended limits on the same AUDIT-C. Alternatively, they can screen negative based on the AUDIT-C score while reporting drinking above US recommended limits. Such inconsistencies could complicate interpretation of screening results, but it is unclear how often they occur in practice.

Methods

This study used AUDIT-C data from respondents who reported past-year drinking on one of two national US surveys: a general population survey (N = 26,610) and a Veterans Health Administration (VA) outpatient survey (N = 467,416). Gender-stratified analyses estimated the prevalence of AUDIT-C screen results—positive or negative screens based on the AUDIT-C score—that were inconsistent with reported drinking (above or below US recommended limits) on the same AUDIT-C.

Results

Among men who reported drinking, 13.8% and 21.1% of US general population and VA samples, respectively, had screening results based on AUDIT-C scores (positive or negative) that were inconsistent with reported drinking on the AUDIT-C questions (above or below US recommended limits). Among women who reported drinking, 18.3% and 20.7% of US general population and VA samples, respectively, had screening results that were inconsistent with reported drinking.

Limitations

This study did not include an independent interview gold standard for unhealthy alcohol use and therefore cannot address how often observed inconsistencies represent false positive or negative screens.

Conclusions

Up to 21% of people who drink alcohol had alcohol screening results based on the AUDIT-C score that were inconsistent with reported drinking on the same AUDIT-C. This needs to be addressed when training clinicians to use the AUDIT-C.

Substance use among women veterans: epidemiology to evidence-based treatment

An increasing percentage of women are U.S. Military Veterans. We review the substance misuse rates and comorbidities and the risk factors for and consequences of substance use among women Veterans. Women Veterans may have higher rates of substance misuse and comorbid psychiatric and medical disorders than male Veterans and women who are not Veterans. Studies support the AUDIT-C as a scaled marker of alcohol-related risk among female Veterans, but validated drug screening instruments are needed. We discuss evidence-based approaches in terms of treating women Veterans' substance misuse in primary and specialty care settings, along with knowledge gaps and potential research priorities to improve care in this special population.

Probability and predictors of patients converting from negative to positive screens for alcohol misuse

BACKGROUND

Medicare reimburses providers for annual alcohol screening. However, the benefit of rescreening patients a year after a negative screen for alcohol misuse is unknown. We hypothesized that some subgroups of patients who screen negative would have a very low probability of converting to a positive subsequent screen (e.g., <0.1%), calling into question the value of annual alcohol screening for some patient subgroups.

METHODS

This retrospective cohort study estimated the probability of converting to a positive screen for alcohol misuse a year after a negative screen among outpatients from 30 Veterans Health Administration (VA) medical centers. Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) alcohol screening scores (range 0 to 12 points) from 2004 to 2008 were obtained from electronic health record data. Eligible patients screened negative on their initial screen (AUDIT-C scores 0 to 3 for men; 0 to 2 for women). The main outcome was a positive subsequent screen (AUDIT-C scores ≥4 men; ≥3 women).

RESULTS

Among 21,081 women and 323,913 men who screened negative on an initial screen, 5.4% and 6.0%, respectively, screened positive a year later. The adjusted probability of converting to a positive subsequent screen varied from 2.1 to 38.9% depending on age, gender, and initial negative screen score. Women, older patients, and those with initial AUDIT-C scores of 0 were least likely to a convert to a positive subsequent screen, while younger men with AUDIT-C scores of 3 were most likely to a convert to a positive subsequent screen.

CONCLUSIONS

The probability of a positive subsequent screen varied depending on age, gender, and initial negative screen score but exceeded 2% in all patient subgroups. Annual rescreening appears reasonable for all VA patients who had a negative screen the year prior.

Diagnostic efficiency of the AUDIT-C in U.S. veterans with military service since September 11, 2001

BACKGROUND

Alcohol screening with the 3-item alcohol use disorders identification test (AUDIT-C) has been implemented throughout the U.S. Veterans Health Administration. Validation of the AUDIT-C, however, has been conducted with samples of primarily older veterans. This study examined the diagnostic efficiency of the AUDIT-C in a younger cohort of veterans who served during Operation Enduring Freedom and/or Operation Iraqi Freedom (OEF/OIF).

METHODS

Veteran participants (N=1775) completed the alcohol use disorders identification test (AUDIT) and underwent the structured clinical interview for DSM-IV-TR for Axis I disorders (SCID) in research settings within four VA medical Centers. Areas under receiver operating characteristic curves (AUCs) measured the effiency of the full AUDIT and AUDIT-C in identifying SCID-based diagnoses of past year alcohol abuse or dependence.

RESULTS

Both measures performed well in detecting alcohol use disorders. In the full sample, the AUDIT had a better AUC (.908; .881-.935) than the AUDIT-C (.859; .826-.893; p<.0001). It is notable that this same result was found among men but not women, perhaps due to reduced power. Diagnostic efficiency statistics for the AUDIT and AUDIT-C were consistent with results from older veteran samples. The diagnostic efficiency of both measures did not vary with race or age.

CONCLUSIONS

Both the AUDIT and AUDIT-C appear to be valid instruments for identifying alcohol abuse or dependence among the most recent cohort of U.S. veterans with service during OEF/OIF within research settings.

Alcohol questionnaires and HDL: screening scores as scaled markers of alcohol consumption

Improving the quality of alcohol-related care requires practical approaches to assessing alcohol consumption to guide management and monitor outcomes. Given the increasing use of alcohol screening questionnaires to identify alcohol misuse it would be ideal if scores on screening questionnaires were also indicators of average alcohol consumption. However, the questionnaires were not designed for this purpose and include dimensions of drinking that may not reflect average consumption (e.g. heavy episodic drinking, alcohol-related problems). In a general population sample, scores on the AUDIT-C screen correlated with reports of alcohol consumption in detailed interviews, but the relationship is unknown for clinical populations and other questionnaires. Serum high-density lipoprotein cholesterol (HDL) is a biomarker routinely obtained in clinical care and is known to rise with average alcohol consumption. This cross-sectional study of 11,175 male U.S. Veterans Affairs patients enrolled in a primary care study used HDL as an objective biomarker to evaluate whether average alcohol consumption increased as scores increased on 3 brief alcohol screens - the AUDIT-C, AUDIT Question #3 (a single-item screen), and the CAGE questionnaire. Mean HDL progressively increased as screening scores increased for the AUDIT-C and AUDIT Question #3: about 12 mg/dL from the lowest to the highest scores. The association was much weaker for the CAGE questionnaire. Results were minimally affected by adjustment for covariates (e.g. age, race, medical comorbidity, smoking, medication count, and depression) but the association was modified (p = 0.008) and mildly attenuated by adherent use of lipid-lowering medications. This study using HDL as a biomarker of average alcohol consumption adds to evidence that some alcohol screening scores may also serve as scaled markers of average alcohol consumption.

Alcohol consumption is associated with lower self-reported disease activity and better health-related quality of life in female rheumatoid arthritis patients in Sweden: data from BARFOT, a multicenter study on early RA

Background

Earlier studies have found a positive effect of alcohol consumption, with a reduced disease activity in rheumatoid arthritis (RA). The aim of this study was to assess alcohol consumption and its association with disease activity and health related quality of life (HRQL) in Swedish RA patients.

Methods

Between 1992 and 2005, 2,800 adult patients were included in the BARFOT study of early RA in Sweden. In 2010 a self-completion postal questionnaire was sent to all 2,102 prevalent patients in the BARFOT study enquiring about disease severity, HRQL, and lifestyle factors. Alcohol consumption was assessed using the validated AUDIT-C questionnaire.

Results

A total of 1,238 out of 1,460 patients answering the questionnaire had data on alcohol consumption: 11% were non-drinkers, 67% had a non-hazardous drinking, and 21% were classified as hazardous drinkers. Women who drank alcohol reported lower disease activity and better HRQL, but there were no association between alcohol consumption and disease activity in men. For current smokers, alcohol use was only associated with fewer patient-reported swollen joints. The outcome was not affected by kind of alcohol consumed.

Conclusions

There was an association between alcohol consumption and both lower self-reported disease activity and higher HRQL in female, but not in male, RA patients.

AUDIT-C scores as a scaled marker of mean daily drinking, alcohol use disorder severity, and probability of alcohol dependence in a U.S. general population sample of drinkers

BACKGROUND

Brief alcohol screening questionnaires are increasingly used to identify alcohol misuse in routine care, but clinicians also need to assess the level of consumption and the severity of misuse so that appropriate intervention can be offered. Information provided by a patient's alcohol screening score might provide a practical tool for assessing the level of consumption and severity of misuse.

METHODS

This post hoc analysis of data from the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) included 26,546 U.S. adults who reported drinking in the past year and answered additional questions about their consumption, including Alcohol Use Disorders Identification Test-Consumption questionnaire (AUDIT-C) alcohol screening. Linear or logistic regression models and postestimation methods were used to estimate mean daily drinking, the number of endorsed alcohol use disorder (AUD) criteria ("AUD severity"), and the probability of alcohol dependence associated with each individual AUDIT-C score (1 to 12), after testing for effect modification by gender and age.

RESULTS

Among eligible past-year drinkers, mean daily drinking, AUD severity, and the probability of alcohol dependence increased exponentially across increasing AUDIT-C scores. Mean daily drinking ranged from < 0.1 to 18.0 drinks/d, AUD severity ranged from < 0.1 to 5.1 endorsed AUD criteria, and probability of alcohol dependence ranged from < 1 to 65% across scores 1 to 12. AUD severity increased more steeply across AUDIT-C scores among women than men. Both AUD severity and mean daily drinking increased more steeply across AUDIT-C scores among younger versus older age groups.

CONCLUSIONS

Results of this study could be used to estimate patient-specific consumption and severity based on age, gender, and alcohol screening score. This information could be integrated into electronic decision support systems to help providers estimate and provide feedback about patient-specific risks and identify those patients most likely to benefit from further diagnostic assessment.

Association between alcohol screening scores and mortality in black, Hispanic, and white male veterans

BACKGROUND

Scores on the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questionnaire are associated with mortality, but whether or how associations vary across race/ethnicity is unknown.

METHODS

Self-reported black (n = 13,068), Hispanic (n = 9,466), and white (n = 182,688) male Veterans Affairs (VA) outpatients completed the AUDIT-C via mailed survey. Logistic regression models evaluated whether race/ethnicity modified the association between AUDIT-C scores (0, 1 to 4, 5 to 8, and 9 to 12) and mortality after 24 months, adjusting for demographics, smoking, and comorbidity.

RESULTS

Adjusted mortality rates were 0.036, 0.033, and 0.054, for black, Hispanic, and white patients with AUDIT-C scores of 1 to 4, respectively. Race/ethnicity modified the association between AUDIT-C scores and mortality (p = 0.0022). Hispanic and white patients with scores of 0, 5 to 8, and 9 to 12 had significantly increased risk of death compared to those with scores of 1 to 4; Hispanic ORs: 1.93, 95% CI 1.50 to 2.49; 1.57, 1.07 to 2.30; 1.82, 1.04 to 3.17, respectively; white ORs: 1.34, 95% CI 1.29 to 1.40; 1.12, 1.03 to 1.21; 1.81, 1.59 to 2.07, respectively. Black patients with scores of 0 and 5 to 8 had increased risk relative to scores of 1 to 4 (ORs 1.28, 1.06 to 1.56 and 1.50, 1.13 to 1.99), but there was no significant increased risk for scores of 9 to 12 (ORs 1.27, 0.77 to 2.09). Post hoc exploratory analyses suggested an interaction between smoking and AUDIT-C scores might account for some of the observed differences across race/ethnicity.

CONCLUSIONS

Among male VA outpatients, associations between alcohol screening scores and mortality varied significantly depending on race/ethnicity. Findings could be integrated into systems with automated risk calculators to provide demographically tailored feedback regarding medical consequences of drinking.

Risk of future trauma based on alcohol screening scores: a two-year prospective cohort study among US veterans

BACKGROUND

Severe alcohol misuse as measured by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is associated with increased risk of future fractures and trauma-related hospitalizations. This study examined the association between AUDIT-C scores and two-year risk of any type of trauma among US Veterans Health Administration (VHA) patients and assessed whether risk varied by age or gender.

METHODS

Outpatients (215, 924 male and 9168 female) who returned mailed AUDIT-C questionnaires were followed for 24 months in the medical record for any International Statistical Classification of Diseases and Related Health Problems (ICD-9) code related to trauma. The two-year prevalence of trauma was examined as a function of AUDIT-C scores, with low-level drinking (AUDIT-C 1-4) as the reference group. Men and women were examined separately, and age-stratified analyses were performed.

RESULTS

Having an AUDIT-C score of 9-12 (indicating severe alcohol misuse) was associated with increased risk for trauma. Mean (SD) ages for men and women were 68.2 (11.5) and 57.2 (15.8), respectively. Age-stratified analyses showed that, for men≤50 years, those with AUDIT-C scores≥9 had an increased risk for trauma compared with those with AUDIT-C scores in the 1-4 range (adjusted prevalence, 25.7% versus 20.8%, respectively; OR=1.24; 95% confidence interval [CI], 1.03-1.50). For men≥65 years with average comorbidity and education, those with AUDIT-C scores of 5-8 (adjusted prevalence, 7.9% versus 7.4%; OR=1.16; 95% CI, 1.02-1.31) and 9-12 (adjusted prevalence 11.1% versus 7.4%; OR=1.68; 95% CI, 1.30-2.17) were at significantly increased risk for trauma compared with men≥65 years in the reference group. Higher AUDIT-C scores were not associated with increased risk of trauma among women.

CONCLUSIONS

Men with severe alcohol misuse (AUDIT-C 9-12) demonstrate an increased risk of trauma. Men≥65 showed an increased risk for trauma at all levels of alcohol misuse (AUDIT-C 5-8 and 9-12). These findings may be used as part of an evidence-based brief intervention for alcohol use disorders. More research is needed to understand the relationship between AUDIT-C scores and risk of trauma in women.

Alcohol screening scores and the risk of new-onset gastrointestinal illness or related hospitalization

BACKGROUND

Excessive alcohol use is associated with a variety of negative health outcomes, including liver disease, upper gastrointestinal bleeding, and pancreatitis.

OBJECTIVE

To determine the 2-year risk of gastrointestinal-related hospitalization and new-onset gastrointestinal illness based on alcohol screening scores.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Male (N = 215, 924) and female (N = 9,168) outpatients who returned mailed questionnaires and were followed for 24 months.

MEASUREMENTS

Alcohol Use Disorder Identification Test-Consumption Questionnaire (AUDIT-C), a validated three-item alcohol screening questionnaire (0-12 points).

RESULTS

Two-year risk of hospitalization with a gastrointestinal disorder was increased in men with AUDIT-C scores of 5-8 and 9-12 (OR 1.54, 95% CI = 1.27-1.86; and OR 3.27; 95% CI = 2.62-4.09 respectively), and women with AUDIT-C scores of 9-12 (OR 6.84, 95% CI = 1.85 - 25.37). Men with AUDIT-C scores of 5-8 and 9-12 had increased risk of new-onset liver disease (OR 1.49, 95% CI = 1.30-1.71; and OR 2.82, 95% CI = 2.38-3.34 respectively), and new-onset of upper gastrointestinal bleeding (OR 1.28, 95% CI = 1.05-1.57; and OR 2.14, 95% CI = 1.54-2.97 respectively). Two-year risk of new-onset pancreatitis in men with AUDIT -C scores 9-12 was also increased (OR 2.14; 95% CI = 1.54-2.97).

CONCLUSIONS

Excessive alcohol use as determined by AUDIT-C is associated with 2-year increased risk of gastrointestinal-related hospitalization in men and women and new-onset liver disease, upper gastrointestinal bleeding, and pancreatitis in men. These results provide risk information that clinicians can use in evidence-based conversations with patients about their alcohol consumption.