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

High-density lipoprotein (HDL) as an indicator for alcohol use in a psychiatrically ill population

AIMS

To examine the cross sectional and longitudinal associations between the Alcohol Use Disorders Identification Test-Concise (AUDIT-C) and differences in high-density lipoprotein (HDL) in a psychiatrically ill population.

METHODS

Retrospective observational study using electronic health record data from a large healthcare system, of patients hospitalized for a mental health/substance use disorder (MH/SUD) from 1 July 2016 to 31 May 2023, who had a proximal AUDIT-C and HDL (N = 15 915) and the subset who had a repeat AUDIT-C and HDL 1 year later (N = 2915). Linear regression models examined the association between cross-sectional and longitudinal AUDIT-C scores and HDL, adjusting for demographic and clinical characteristics that affect HDL.

RESULTS

Compared with AUDIT-C score = 0, HDL was higher among patients with greater AUDIT-C severity (e.g. moderate AUDIT-C score = 8.70[7.65, 9.75] mg/dl; severe AUDIT-C score = 13.02 [12.13, 13.90] mg/dL[95% confidence interval (CI)] mg/dl). The associations between cross-sectional HDL and AUDIT-C scores were similar with and without adjusting for patient demographic and clinical characteristics. HDL levels increased for patients with mild alcohol use at baseline and moderate or severe alcohol use at follow-up (15.06[2.77, 27.69] and 19.58[2.77, 36.39] mg/dL[95%CI] increase for moderate and severe, respectively).

CONCLUSIONS

HDL levels correlate with AUDIT-C scores among patients with MH/SUD. Longitudinally, there were some (but not consistent) increases in HDL associated with increases in AUDIT-C. The increases were within range of typical year-to-year variation in HDL across the population independent of alcohol use, limiting the ability to use HDL as a longitudinal clinical indicator for alcohol use in routine care.

Perspectives of clinical stakeholders and patients from four VA liver clinics to tailor practice facilitation for implementing evidence-based alcohol-related care

BACKGROUND

Unhealthy alcohol use (UAU) is particularly dangerous for people with chronic liver disease. Liver clinics may be an important setting in which to provide effective alcohol-related care by integrating evidence-based strategies, such as brief intervention and medications for alcohol use disorder. We conducted qualitative interviews with clinical stakeholders and patients at liver clinics in four Veterans Health Administration (VA) medical centers to understand barriers and facilitators of integrating alcohol-related care and to support tailoring of a practice facilitation implementation intervention.

METHODS

Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed and qualitatively analyzed using a Rapid Assessment Process (RAP) guided by the CFIR.

RESULTS

We interviewed 46 clinical stakeholders and 41 patient participants and analyzed findings based on the CFIR. Clinical stakeholders described barriers and facilitators that ranged from operations/clinic resource-based (e.g., time and capacity, desire for additional provider types, referral processes) to individual perspective and preference-based (e.g., supportiveness of leadership, individual experiences/beliefs). Patient participants shared barriers and facilitators that ranged from relationship-based (e.g., trusting the provider and feeling judged) to resource and education-based (e.g., connection to a range of treatment options, education about impact of alcohol). Many barriers and facilitators to integrating alcohol-related care in liver clinics were similar to those identified in other clinical settings (e.g., time, resources, role clarity, stigmatizing beliefs). However, some barriers (e.g., fellow-led care and lack of integration of liver clinics with addictions specialists) and facilitators (e.g., presence of quality improvement staff in clinics and integrated pharmacists and behavioral health specialists) were more unique to liver clinics.

CONCLUSIONS

These findings support the possibility of integrating alcohol-related care into liver clinics but highlight the importance of tailoring efforts to account for variation in provider beliefs and experiences and clinic resources. The barriers and facilitators identified in these interviews were used to tailor a practice facilitation implementation intervention in each clinic setting.

Psychoactive substances and previous hospital admissions, triage and length of stay in rural injuries: a prospective observational study

BACKGROUND

Patients admitted to hospital after an injury are often found to have used psychoactive substances prior to the injury. The aim of this study was to investigate the associations between psychoactive substances (alcohol, psychoactive medicinal drugs and illicit drugs) and previous hospital admissions, triage and length of stay in the arctic Norwegian county of Finnmark.

METHODS

Patients ≥ 18 years admitted due to injury to trauma hospitals in Finnmark from January 2015 to August 2016 were approached. Parameters regarding admittance and hospital stay were collected from 684 patients and blood was analysed for psychoactive substances. Using a prospective, observational design, time, triage, length of stay in hospital, use of intensive care unit (ICU), injury severity, Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) and number of previous admittances were investigated by bivariable testing and logistical regression analysis.

RESULTS

Of 943 patients approached, 81% consented and 684 were included in the study. During the weekend, 51.5% tested positive for any substance versus 27.1% Monday-Friday. No associations were identified between testing positive and either triage or injury severity for any substance group although triage level was lower in patients with AUDIT-C ≥ 5. Short length of stay was associated with alcohol use prior to injury [odds ratio (OR) 0.48 for staying > 12 h, confidence interval (CI) 0.25-0.90]. The OR for staying > 24 h in the ICU when positive for an illicit substance was 6.33 (CI 1.79-22.32) while negatively associated with an AUDIT-C ≥ 5 (OR 0.30, CI 0.10-0.92). Patients testing positive for a substance had more often previously been admitted with the strongest association for illicit drugs (OR 6.43 (CI 1.47-28.08), compared to patients in whom no substances were detected.

CONCLUSIONS

Triage level and injury severity were not associated with psychoactive substance use. Patients using alcohol are more often discharged early, but illicit substances were associated with longer ICU stays. All psychoactive substance groups were associated with having been previously admitted.

Preliminary Clinical Outcomes of the Hello Sunday Morning Alcohol and Wellbeing Self-Assessment: Feasibility and Acceptability Study

BACKGROUND

Alcohol-related injuries and diseases are a leading cause of morbidity and mortality worldwide. Early intervention is essential given the chronic, relapsing nature of alcohol use disorders. There is significant potential for widely accessible web-based screening tools to help individuals determine where they stand in terms of alcohol use and provide support recommendations. Screening and brief interventions (SBIs) provide individuals with a stigma-free opportunity to learn and think about the potential risks of drinking and prompt help-seeking behavior by incorporating behavior change techniques. Furthermore, as excessive alcohol use and mental health problems often occur concurrently, SBIs for both conditions simultaneously can potentially address a critical gap in alcohol and mental health treatment.

OBJECTIVE

We investigated the feasibility, acceptability, and clinical outcomes of participants completing the Alcohol and Wellbeing Self-assessment (A&WS), a web-based SBI.

METHODS

The A&WS is freely available on the Hello Sunday Morning website as part of an uncontrolled observational prospective study. Feasibility was assessed based on the number of respondents who commenced and subsequently completed the A&WS. Acceptability was measured via participant feedback to determine overall satisfaction, perceived helpfulness, and likelihood of recommending the A&WS to others. Clinical outcomes were measured in two ways: (1) self-reported changes in alcohol consumption (Alcohol Use Disorders Identification Test score) or psychological distress (Kessler Psychological Distress Scale score) over time and (2) help seeking-both self-reported and immediate web-based help seeking. Preliminary baseline data collected for the first 9 months (March 2022 to December 2022) of the study were reported, including the 3-month follow-up outcomes.

RESULTS

A total of 17,628 participants commenced the A&WS, and of these, 14,419 (81.8%) completed it. Of those 14,419 who completed the A&WS, 1323 (9.18%) agreed to participate in the follow-up research. Acceptability was high, with 78.46% (1038/1323) reporting high satisfaction levels overall; 95.62% (1265/1323) found the A&WS easy to use and would recommend the tool to others. The 1-, 2-, and 3-month follow-ups were completed by 28.57% (378/1323), 21.09% (279/1323), and 17.61% (233/1323) of the participants, respectively. Significant reductions in the Alcohol Use Disorders Identification Test Consumption subscale (P<.001) and Kessler Psychological Distress Scale scores (P<.001) were observed over the 3-month follow-up period.

CONCLUSIONS

Our results suggest that the A&WS is a highly feasible and acceptable digital SBI that may support individuals in making changes to their alcohol consumption and improve their psychological well-being. In the absence of a control group, positive clinical outcomes cannot be attributed to the A&WS, which should now be subjected to a randomized controlled trial. This scalable, freely available tool has the potential to reach a large number of adults who might not otherwise access help while complementing the alcohol and mental health treatment ecosystem.

Associations between serum high-density lipoprotein cholesterol levels and cause-specific mortality in a general population of 345 000 men and women aged 20-79 years

BACKGROUND

Benefits of elevated high-density lipoprotein cholesterol (HDL-C) levels are challenged by reports demonstrating U-shaped relations between HDL-C levels and all-cause mortality; the association with cause-specific mortality is less studied.

METHODS

A total of 344 556 individuals (20-79 years, 52 % women) recruited from population-based health screening during 1985-2003 were followed until the end of 2018 for all-cause and cause-specific mortality by serum HDL-C level at inclusion of <30, 30-39, 40-49, 50-59, 60-69, 70-79, 80-89, 90-99 and >99 mg/dl (< 0.78, 0.78-1.01, 1.04-1.27, 1.30-1.53, 1.55-1.79, 1.81-2.04, 2.07-2.31, 2.33-2.56, >2.56 mmol/L). Hazard ratios (HRs) were adjusted for sex, age, calendar period, smoking, total cholesterol, triglycerides, systolic blood pressure, physical activity, educational length, body mass index and ill health.

RESULTS

During a mean follow-up of 22 years, 69 505 individuals died. There were U-shaped associations between HDL-C levels and all-cause, cancer and non-cardiovascular disease/non-cancer mortality (non-CVD/non-cancer), whereas for CVD there was increased risk of death only at lower levels. With HDL-C stratum 50-59 mg/dl (1.30-1.53 mmol/L) as reference, HRs [95% confidence intervals (CIs)] for levels >99 mg/dl (>2.56 mmol/L) were 1.32 (1.21-1.43), 1.05 (0.89-1.24), 1.26 (1.09-1.46) and 1.68 (1.48-1.90) for all-cause, CVD, cancer and non-CVD/non-cancer mortality, respectively. For HDL-C levels <30 mg/dl (0.78 mmol/L), the corresponding HRs (95% CIs) were 1.30 (1.24-1.36), 1.55 (1.44-1.67), 1.14 (1.05-1.23) and 1.19 (1.10-1.29). The mortality from alcoholic liver disease, cancers of mouth-oesophagus-liver, chronic liver diseases, chronic obstructive pulmonary disease, accidents and diabetes increased distinctly with increasing HDL-C above the reference level. HDL-C levels lower than the reference level were mainly associated with increased mortality of ischaemic heart disease (IHD), other CVDs, stomach cancer and diabetes.

CONCLUSIONS

Higher HDL-C levels were associated with increased mortality risk of several diseases which also have been associated with heavy drinking, and lower HDL-C levels were associated with increased mortality from IHD, other CVDs, gastric cancer and diabetes.

Changes in alcohol consumption reported on routine healthcare screenings are associated with changes in depression symptoms

BACKGROUND

The Alcohol Use Disorders Identification Test-Consumption version (AUDIT-C) has been robustly validated as a point-in-time screen for unhealthy alcohol use, but less is known about the significance of changes in AUDIT-C scores from routine screenings over time. Unhealthy alcohol use and depression commonly co-occur, and changes in drinking often co-occur with changes in depression symptoms. We assess the associations between changes in AUDIT-C scores and changes in depression symptoms reported on brief screens completed in routine care.

METHODS

The study sample included 198,335 primary care patients who completed two AUDIT-C screens 11 to 24 months apart and the Patient Health Questionnaire-2 (PHQ-2) depression screen on the same day as each AUDIT-C. Both screening measures were completed as part of routine care within a large health system in Washington state. AUDIT-C scores were categorized to reflect five drinking levels at both time points, resulting in 25 subgroups with different change patterns. For each of the 25 subgroups, within-group changes in the prevalence of positive PHQ-2 depression screens were characterized using risk ratios (RRs) and McNemar's tests.

RESULTS

Patient subgroups with increases in AUDIT-C risk categories generally experienced increases in the prevalence of positive depression screens (RRs ranging from 0.95 to 2.00). Patient subgroups with decreases in AUDIT-C risk categories generally experienced decreases in the prevalence of positive depression screens (RRs ranging from 0.52 to 1.01). Patient subgroups that did not have changes in AUDIT-C risk categories experienced little or no change in the prevalence of positive depression screens (RRs ranging from 0.98 to 1.15).

CONCLUSIONS

As hypothesized, changes in alcohol consumption reported on AUDIT-C screens completed in routine care were associated with changes in depression screening results. Results support the validity and clinical utility of monitoring changes in AUDIT-C scores over time as a meaningful measure of changes in drinking.

Nonsuicidal self-injury among veterans is associated with psychosocial impairment, suicidal thoughts and behaviors, and underutilization of mental health services

Nonsuicidal self-injury (NSSI) is a robust predictor of suicide attempts. However, understanding of NSSI and associated treatment utilization among Veterans is limited. Although impairment may be assumed, few studies examine the association between NSSI and psychosocial functioning, a core component of the rehabilitation framework of mental health. In a national survey of Veterans, current NSSI (n = 88) was associated with higher rates of suicidal thoughts and behaviors and more severe psychosocial impairment after adjusting for demographics and probable diagnoses of posttraumatic stress disorder, major depressive disorder, and alcohol use disorder, compared to Veterans without NSSI (n = 979). Only half of Veterans with NSSI were engaged with mental health services, with few appointments attended, suggesting that these Veterans are not receiving treatment interventions. Results underscore the adverse outcomes associated with NSSI. Underutilization of mental health services highlights the importance of screening for NSSI among Veterans to improve psychosocial outcomes.

Substance Use in U.S. Vietnam War Era Veterans and Nonveterans: Results from the Vietnam Era Health Retrospective Observational Study

Background: Substance use (SU) is associated with physical injury and mental health disorders in older persons, but recent research has scarcely examined SU in U.S. Vietnam-era veterans who are mostly in or near their eighth decade of life. Objectives: We compared the prevalence of self-reported lifetime and current SU and modeled current usage patterns in a nationally representative sample of veterans versus a matched nonveteran cohort. Methods: Cross-sectional, self-reported survey data were analyzed from the 2016-2017 Vietnam Era Health Retrospective Observational Study (VE-HEROeS) (n = 18,866 veterans, n = 4,530 nonveterans). We assessed lifetime and current alcohol and drug use disorders; lifetime and current use of cannabis, opioids, stimulants, sedatives, "other drugs" (psychedelics, prescription or over-the-counter drugs not prescribed/used as intended); and current SU patterns (alcohol-use-only, drug-use-only, dual-SU, no SU). Weighted descriptive, bivariable, and multivariable statistics were calculated. Covariates in multinomial modeling included sociodemographic characteristics, lifetime cigarette smoking, depression, potentially traumatic events (PTEs), and current pain (SF-8^TM). Results: Prevalence of lifetime opioid and sedative use (p ≤ .01), drug and alcohol use disorders (p < .001), and current "other drug" use (p < .001) were higher in veterans versus nonveterans. Current use of alcohol and cannabis was high in both cohorts. In veterans, very severe/severe pain, depression, and PTEs were highly associated with drug-use-only (p < .001) and dual-SU (p < .01), but these associations were fewer for nonveterans. Conclusion: This research confirmed existing concerns over substance misuse in older individuals. Vietnam-era veterans may be at particular risk due to service-related experiences and later-life tribulations. Era veterans' unique perceptions toward healthcare assistance for SU may need greater provider focus to maximize self-efficacy and treatment.

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.

A national population-based study of cannabis use and correlates among U.S. veterans prescribed opioids in primary care

BACKGROUND

Cannabis is marketed as a treatment for pain. There is limited data on the prevalence of cannabis use and its correlates among Veterans prescribed opioids.

OBJECTIVE

To examine the prevalence and correlates of cannabis use among Veterans prescribed opioids.

DESIGN

Cross-sectional study.

PARTICIPANTS

Veterans with a urine drug test (UDT) from Primary Care 2014-2018, in 50 states, Washington, D.C., and Puerto Rico. A total of 1,182,779 patients were identified with an opioid prescription within 90 days prior to UDT.

MAIN MEASURES

Annual prevalence of cannabis positive UDT by state. We used multivariable logistic regression to assess associations of demographic factors, mental health conditions, substance use disorders, and pain diagnoses with cannabis positive UDT.

RESULTS

Annual prevalence of cannabis positive UDT ranged from 8.5% to 9.7% during the study period, and in 2018 was 18.15% in Washington, D.C. and 10 states with legalized medical and recreational cannabis, 6.1% in Puerto Rico and 25 states with legalized medical cannabis, and 4.5% in non-legal states. Younger age, male sex, being unmarried, and marginal housing were associated with use (p < 0.001). Post-traumatic stress disorder (adjusted odds ratio [AOR] 1.17; 95% confidence interval [CI] 1.13-1.22, p < 0.001), opioid use disorder (AOR 1.14; CI 1.07-1.22, p < 0.001), alcohol use disorder or positive AUDIT-C (AOR 1.34; 95% CI 1.28-1.39, p < 0.001), smoking (AOR 2.58; 95% CI 2.49-2.66, p < 0.001), and other drug use disorders (AOR 1.15; 95% CI 1.03-1.29, p = 0.02) were associated with cannabis use. Positive UDT for amphetamines AOR 1.41; 95% CI 1.26-1.58, p < 0.001), benzodiazepines (AOR 1.41; 95% CI 1.31-1.51, p < 0.001) and cocaine (AOR 2.04; 95% CI 1.75-2.36, p < 0.001) were associated with cannabis positive UDT.

CONCLUSIONS

Cannabis use among Veterans prescribed opioids varied by state and by legalization status. Veterans with PTSD and substance use disorders were more likely to have cannabis positive UDT. Opioid-prescribed Veterans using cannabis may benefit from screening for these conditions, referral to treatment, and attention to opioid safety.

Using the alcohol use disorders identification test to predict hospital admission for alcohol-related conditions in the Danish general population: a record-linkage study

BACKGROUND AND AIMS

Most studies validating the alcohol use disorders identification test (AUDIT) have either assessed its factor structure and/or test-retest reliability or used diagnostic interviews as validators of current alcohol use disorders. The aim of the present study was to determine whether AUDIT and AUDIT-Consumption (AUDIT-C) scores are associated with subsequent risk of hospital admission for alcohol-related disorders and diseases (ARDDs).

DESIGN

We used a historical cohort study. Using national registers, survey respondents were tracked from 1 September 2011 to hospitalization for an ARDD, emigration, death, or 31 December 2018, whichever occurred first.

SETTING

Denmark.

PARTICIPANTS

Respondents (n = 4522) from a Danish national survey conducted in autumn 2011.

MEASUREMENTS

Outcome was incident ARDD admission recorded in the National Patient Register. Predictors were AUDIT and AUDIT-C scores, and covariates were age, gender, highest level of education and previous psychiatric disorder.

FINDINGS

During the study period, 56 respondents had a first-time ARDD admission. Respondents who scored above the 8-point AUDIT cut-off and respondents who scored above the 5-point AUDIT-C cut-off had a significantly increased risk of being admitted for an ARDD compared with respondents who scored below the cut-offs, (AUDIT: hazard ratio (HR), 4.72; 95% CI, 2.59-8.60; AUDIT-C: HR, 7.97; 95% CI, 3.66-17.31).

CONCLUSIONS

Scores above alcohol use disorders identification test (AUDIT) and AUDIT-Consumption (AUDIT-C) cut-offs are associated with an increased risk of long-term alcohol-related hospital admissions. At widely used cut-offs, the AUDIT-C is a better predictor of alcohol-related hospitalizations among members of the general population than the full AUDIT.

Cost-effectiveness of direct-acting antivirals for chronic hepatitis C virus in the United States from a payer perspective

BACKGROUND: Direct-acting antivirals (DAAs) have been a breakthrough therapeutic innovation in the treatment of chronic hepatitis C virus (HCV) with significantly improved efficacy, safety, and tolerability. OBJECTIVE: To evaluate the cost-effectiveness of treating patients with HCV with DAAs compared with pre-DAAs or no treatment over a lifetime horizon from the perspective of the US Veterans Affairs (VA) health care system. METHODS: A hybrid decision-tree and Markov model simulated the health outcomes of a cohort of 142,147 patients with HCV with an average age of 63 years. Demographic data, treatment rates and distribution, treatment efficacy by subpopulation, and health state costs were sourced from VA data. Treatment costs and utility values were sourced from publicly available databases and prior publications for older regimens. RESULTS: Over a lifetime horizon, the use of DAAs results in a significant reduction in advanced liver disease events compared with pre-DAA and no treatment. Total cost savings of $7 and $9 billion over a lifetime horizon (50 years) were predicted for patients who received DAA treatments compared with patients treated with pre-DAA treatments and those who were untreated, respectively. Cost savings were achieved quickly after treatment, with DAAs being inexpensive when compared with both the pre-DAA and untreated scenarios within 5 years. The DAA intervention dominated (ie, more effective and less costly) for both the pre-DAA and untreated strategies on both a per-patient and cohort basis. CONCLUSIONS: The use of DAA-based treatments in patients with HCV in the VA system significantly reduced long-term HCV-related morbidity and mortality, while providing cost savings within only 5 years of treatment. DISCLOSURES: This work was supported by Gilead Inc. Health Economic Outcomes Research group, grant number GS-US-18-HCV003. Drs Yehoshua and Kaushik are employees of Gilead in the Health Economic Outcome Research group. These individuals reviewed the manuscript but did not contribute to input or output of the Markov model. Maple Health Group (Dr El-Moustaid, Ms Raad, and Dr Smith) are consultants hired by Gilead for Markov modeling expertise. The model used in this study was previously published and peer reviewed. Data inputted into the model related to patient demographic, treatment outcomes, clinical outcomes, and costs were completely independent in derivation by Drs Kaplan, Serper, and Durkin and were not influenced by the funding sponsor. Dr Kaplan reports grants from Gilead Inc. during the conduct of the study and grants from Gilead Inc., other from Glycotest Inc., other from AstraZeneca, other from Exact Sciences, and other from Bayer outside the submitted work.

Self-reported pain among Cambodian Americans with depression: patient-provider communication as an overlooked social determinant

Objectives

Pain is common among torture survivors and refugees. Clear communication about one’s pain is vital to timely and precise diagnosis and treatment but is rarely recognized as a social determinant of health. We examined whether self-reported difficulty communicating with their health care provider, along with standard social determinants, is associated with self-reported pain in Cambodian American refugees.

Methods

Secondary data analysis was conducted on n = 186 baseline assessments from a diabetes prevention trial of Cambodian Americans with depression. Bilingual, bicultural community health workers (CHWs) conducted surveys including social determinants of health and past week pain occurrence and interference.

Results

The sample was 78% female, modal household income = $25,000, mean age = 55 years, and mean education = 6.9 years. About one-third had private insurance and two-thirds could not speak English conversationally. The average pain score was 2.8 on a scale from 0–8 with 37% reporting no pain at all. In bivariate analyses, predictors of higher pain scores were higher difficulty understanding healthcare provider, depressive symptoms, trauma symptoms, food insecurity, and social isolation; predictors of lower pain scores were higher years of education, income, English language proficiency, social support, working, and having private insurance. In the multivariate backward elimination model only two predictors were retained: difficulty understanding healthcare provider and depressive symptoms.

Discussion

We propose that healthcare communication is a modifiable social determinant of health. Healthcare institutions should receive the resources necessary to secure patients’ rights to clear communication including trained community health workers.

Psychological distress and health behaviours among Cambodian Americans at risk for developing diabetes

This paper reports secondary data analysis of associations between psychological distress and health behaviours among Cambodian Americans. Data are from baseline assessments from a diabetes prevention trial. All participants met stucriteria for depression and were free of diabetes. Participants (n = 191) completed surveys, a food frequency assessment, and wore sleep and physical activity actigraphy devices for 7 days. A factor analysis of symptoms of post-traumatic stress, baksbat (a Cambodian culture-bound syndrome), depression, and anxiety yielded a single factor named 'psychological distress'. Multivariate models controlling for psychotropic medications were run for the following outcomes: sleep actigraphy, self-reported sleep, physical activity actigraphy, self-reported physical activity, nutrition, and substance use. For actigraphy, higher distress was associated with lower moderate/vigorous physical activity and higher mean variability of 24 h total sleep time. Higher distress was also associated with worse self-reported sleep quality as indicated by standard, and culturally-specific, sleep indicators. Higher distress was also associated with lower use of food labels, lower carbohydrate consumption, and higher alcohol consumption as a coping mechanism. Interventions to mitigate diabetes risk in high-distress populations may benefit from strategies to decrease psychological distress. The sequelae of complex trauma may transcend discrete psychiatric diagnoses.

HPV Vaccination and Cervical Cancer Screening: Assessing Awareness, Attitudes, and Adherence in Detained Women

Background: This study assessed awareness, attitudes, and uptake of human papillomavirus (HPV) vaccination and cervical cancer screening in detained women. Methods: The cross-sectional study was conducted from April to June 2022 in four women prisons in Italy. Results: 41.1% of participants recognized HPV infection as an sexually transmitted diseases (STD), 36.4% identified cervical, and 16.8% oral cancer as an HPV-associated disease. Overall, 70% had never heard of HPV vaccination, and 45.8% believed it is effective to prevent cervical cancer. Among the age-eligible women for HPV vaccination, none reported to have undergone it, nor had talked about it with a physician in the previous year. Only 13.5% declared to have ever undergone cervical cancer screening, and adherence was significantly higher in those who were involved in a working activity in prison, who were aware that HPV infection is an STD and that can cause cervical and oral cancer, and who were older at their first sexual intercourse. Conclusion: These findings documented an extremely low awareness of HPV infection and an unsatisfactory adherence to prevention through HPV vaccination and cervical cancer screening. There is a need for evidence-based interventions for incarcerated women to promote participation in HPV vaccination and cervical cancer screening programs as routine activities.

Relationship of alcohol use and facial flushing to blood pressure and HbA1c among Cambodian populations with dysglycemia in the U.S. and in Cambodia

BACKGROUND AND AIMS

Facial flushing after drinking alcohol, common among Asians, is a phenotype for genes involved in alcohol metabolism.

METHODS

We investigated cross-sectional associations between flushing, alcohol use, blood pressure (BP) and HbA1c among (n = 287) Cambodians with dysglycemia in Cambodia and in the U.S. Participants were categorized as Abstainers, Flushers who drink, or Non-flushers who drink.

RESULTS

Flushers and Non-flushers had similar alcohol use. Flushers had higher BP than Non-flushers and Abstainers, even after controlling for confounders. Findings were similar across countries. Drinkers had higher HbA1c than Abstainers.

CONCLUSIONS

Future research should examine whether reducing alcohol improves cardiometabolic outcomes.

Alcohol-involved overdose deaths in US veterans

BACKGROUND

Alcohol-involved overdose deaths are increasing and often occur with other substances but have been minimally studied compared to other causes of overdose.

METHODS

We used national Veterans Health Administration (VHA) records linked to National Death Index data from 2012 to 2018 to examine trends in alcohol-related overdose mortality. Patient characteristics and treatment receipt were compared across categories of alcohol overdose deaths (alcohol-only, alcohol+opioids which may include additional substances, and alcohol+other substances without opioids).

RESULTS

From 2012-2018, 2421 Veterans died from an alcohol-involved overdose (alcohol-only: 868, alcohol+opioids: 1269, alcohol+other substances: 284). The alcohol-involved overdose rate increased 57% during this period. Compared to those who died of an alcohol-only overdose, Veterans who died from alcohol+opioids and alcohol+other substances were more likely Black or Hispanic, and to have an opioid use disorder, but less likely to live in rural areas or to be diagnosed with alcohol use disorder (AUD). Only 32.5% of those who died from alcohol-involved overdose received treatment in a substance use disorder clinic in the year preceding death, compared to 65.1% seen in mental health and 85.7% in primary care. Only 9.5% of Veterans who died from alcohol overdose received medication treatment for AUD and 24.8% received psychotherapy for AUD in the year preceding death.

CONCLUSIONS

Alcohol overdose is increasing primarily related to overdoses involving opioids and other substances. Most patients did not receive any effective medication or psychotherapy treatments for AUD, suggesting further need to identify those at risk and to target treatment for this vulnerable group in healthcare settings.

Alcohol Consumption, HDL-Cholesterol and Incidence of Colon and Rectal Cancer: A Prospective Cohort Study Including 250,010 Participants

Aims

Alcohol consumption has been linked to colorectal cancer (CRC) and also to the high-density lipoprotein cholesterol level (HDL-C). HDL-C has been associated with the incidence of CRC. The aim of this study was to investigate the association between self-reported alcohol consumption, HDL-C and incidence of CRC, separately for the two sites.

Methods

Altogether, 250,010 participants in Norwegian surveys have been followed-up for an average of 18 years with respect to a first-time outcome of colon or rectal cancer. During follow-up, 3023 and 1439 colon and rectal cancers were registered.

Results

For men, the HR per 1 drink per day was 1.05 with 95% confidence interval (0.98–1.12) for colon and 1.08 (1.02–1.15) for rectal cancer. The corresponding figures for women were 1.03 (0.97–1.10) and 1.05 (1.00–1.10). There was a positive association between alcohol consumption and HDL-C. HDL-C was inversely associated with colon cancer in men (0.74 (0.62–0.89) per 1 mmol/l) and positively associated with rectal cancer, although not statistically significant (1.15 (0.92–1.44). A robust regression that assigned weights to each observation and exclusion of weights ≤ 0.1 increased the HRs per 1 drink per day and decreased the HR per 1 mmol/l for colon cancer. The associations with rectal cancer remained unchanged.

Conclusion

Our results support a positive association between alcohol consumption and colon and rectal cancer, most pronounced for rectal cancer. Considering the positive relation between alcohol consumption and HDL-C, the inverse association between HDL-C and colon cancer in men remains unsettled.

Longitudinal Investigation of Military-specific Factors Associated With Continued Unhealthy Alcohol Use Among a Large US Military Cohort

To examine whether military separation (Veteran), service component (active duty, Reserve/National Guard), and combat deployment are prospectively associated with continuing unhealthy alcohol use among US military service members.

Enlaces Por La Salud: A Personal Health Navigator Intervention Grounded in the Transnational Framework

Despite the disproportionate burden of HIV among Latinxs, there is a paucity of culturally appropriate interventions that have shown efficacy at increasing their engagement and retention in HIV care. We describe the development and implementation of Enlaces, a six-session, individual-level intervention, guided by the transnational framework, to improve HIV care outcomes for newly diagnosed and out-of-care Mexican men and transgender women (TW). Descriptive statistics summarizing baseline data and implementation outcomes are provided. 91 participants enrolled between October 2014 and August 2017. Intervention engagement and satisfaction was high; 81.3% completed all six sessions and 100% were very satisfied/satisfied with their experience. Successful implementation of the ENLACES intervention was the result of establishing client trust and maintaining a flexible, supportive approach to intervention delivery. Use of the transnational framework provided a contextualized approach to engaging with Mexican men and TW living with HIV that can be adapted to other Latino populations.

Clinical impact of chronic substance abuse in a Norwegian ICU-population

BACKGROUND

The clinical impact of chronic substance abuse of alcohol and drugs-referred to as substance use disorders (SUD)-is often overlooked in the intensive care (ICU) setting. The aims of the present study were to identify patients with SUD-regardless of cause of admission-in a mixed Norwegian ICU-population, and to compare patients with and without SUD with regard to clinical characteristics and mortality.

METHODS

Cross-sectional prospective study of a mixed medical and surgical ICU-population aged ≥18 years in Oslo, Norway. Data were collected consecutively, using a questionnaire including the AUDIT-C test, medical records and toxicology results. Patients classified with SUD were divided into the subgroups alcohol use disorders (AUD) and drug use disorders (DUD).

RESULTS

Overall, 222 (26%) of the 861 patients included were classified with SUD; 137 (16%) with AUD and 85 (10%) with DUD. 130/222 (59%) of the SUD-patients had substance abuse-related cause of ICU-admission. Compared to non-SUD patients, DUD-patients were younger (median age 42 vs 65 years) and had lower SAPS II scores (41 vs 46), while AUD-patients had higher SOFA scores (8.0 vs 7.3). Overall, age-adjusted logistic regression analysis showed similar hospital mortality for SUD-patients and non-SUD patients, but AUD was associated with increased mortality among medical patients and in patients with sepsis (OR 1.7 (95% CI 1.0-2.8), and OR 2.6 (95% CI 1.1-6.2)).

CONCLUSION

One in four ICU-patients had SUD regardless of cause of admission. Alcohol use disorder was associated with increased mortality in medical patients and in patients with sepsis.

Association of Bariatric Surgical Procedures With Changes in Unhealthy Alcohol Use Among US Veterans

IMPORTANCE

Bariatric surgical procedures have been associated with increased risk of unhealthy alcohol use, but no previous research has evaluated the long-term alcohol-related risks after laparoscopic sleeve gastrectomy (LSG), currently the most used bariatric procedure. No US-based study has compared long-term alcohol-related outcomes between patients who have undergone Roux-en-Y gastric bypass (RYGB) and those who have not.

OBJECTIVE

To evaluate the changes over time in alcohol use and unhealthy alcohol use from 2 years before to 8 years after a bariatric surgical procedure among individuals with or without preoperative unhealthy alcohol use.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study analyzed electronic health record (EHR) data on military veterans who underwent a bariatric surgical procedure at any of the bariatric centers in the US Department of Veterans Affairs (VA) health system between October 1, 2008, and September 30, 2016. Surgical patients without unhealthy alcohol use at baseline were matched using sequential stratification to nonsurgical control patients without unhealthy alcohol use at baseline, and surgical patients with unhealthy alcohol use at baseline were matched to nonsurgical patients with unhealthy alcohol use at baseline. Data were analyzed in February 2020.

INTERVENTIONS

LSG (n = 1684) and RYGB (n = 924).

MAIN OUTCOMES AND MEASURES

Mean alcohol use, unhealthy alcohol use, and no alcohol use were estimated using scores from the validated 3-item Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), which had been documented in the VA EHR. Alcohol outcomes were estimated with mixed-effects models.

RESULTS

A total of 2608 surgical patients were included in the final cohort (1964 male [75.3%] and 644 female [24.7%] veterans. Mean (SD) age of surgical patients was 53.0 (9.9) years and 53.6 (9.9) years for the matched nonsurgical patients. Among patients without baseline unhealthy alcohol use, 1539 patients who underwent an LSG were matched to 14 555 nonsurgical control patients and 854 patients who underwent an RYGB were matched to 8038 nonsurgical control patients. In patients without baseline unhealthy alcohol use, the mean AUDIT-C scores and the probability of unhealthy alcohol use both increased significantly 3 to 8 years after an LSG or an RYGB, compared with control patients. Eight years after an LSG, the probability of unhealthy alcohol use was higher in surgical vs control patients (7.9% [95% CI, 6.4-9.5] vs 4.5% [95% CI, 4.1-4.9]; difference, 3.4% [95% CI, 1.8-5.0])). Similarly, 8 years after an RYGB, the probability of unhealthy alcohol use was higher in surgical vs control patients (9.2% [95% CI, 8.0-10.3] vs 4.4% [95% CI, 4.1-4.6]; difference, 4.8% [95% CI, 3.6-5.9]). The probability of no alcohol use also decreased significantly 5 to 8 years after both procedures for surgical vs control patients. Among patients with unhealthy alcohol use at baseline, prevalence of unhealthy alcohol use was higher for patients who underwent an RYGB than matched controls.

CONCLUSIONS AND RELEVANCE

In this multi-site cohort study of predominantly male patients, among those who did not have unhealthy alcohol use in the 2 years before bariatric surgery, the probability of developing unhealthy alcohol use increased significantly 3-8 years after bariatric procedures compared with matched controls during follow-up.

Cannabis use, other drug use, and risk of subsequent acute care in primary care patients

BACKGROUND

Cannabis and other drug use is associated with adverse health events, but little is known about the association of routine clinical screening for cannabis or other drug use and acute care utilization. This study evaluated whether self-reported frequency of cannabis or other drug use was associated with subsequent acute care.

METHOD

This retrospective cohort study used EHR and claims data from 8 sites in Washington State that implemented annual substance use screening. Eligible adult primary care patients (N = 47,447) completed screens for cannabis (N = 45,647) and/or other drug use, including illegal drug use and prescription medication misuse, (N = 45,255) from 3/3/15-10/1/2016. Separate single-item screens assessed frequency of past-year cannabis and other drug use: never, less than monthly, monthly, weekly, daily/almost daily. An indicator of acute care utilization measured any urgent care, emergency department visits, or hospitalizations ≤19 months after screening. Adjusted Cox proportional hazards models estimated risk of acute care.

RESULTS

Patients were predominantly non-Hispanic White. Those reporting cannabis use less than monthly (Hazard Ratio [HR] = 1.12, 95 % CI = 1.03-1.21) or daily (HR = 1.24; 1.10-1.39) had greater risk of acute care during follow-up than those reporting no use. Patients reporting other drug use less than monthly (HR = 1.34; 1.13-1.59), weekly (HR = 2.21; 1.46-3.35), or daily (HR = 2.53; 1.86-3.45) had greater risk of acute care than those reporting no other drug use.

CONCLUSION

Population-based screening for cannabis and other drug use in primary care may have utility for understanding risk of subsequent acute care. It is unclear whether findings will generalize to U.S. states with broader racial/ethnic diversity.

HIV care continuum characteristics among people with opioid use disorder and HIV in Vietnam: baseline results from the BRAVO study

BACKGROUND

Little is known about patient characteristics that contribute to initiating antiretroviral therapy (ART) and achieving viral suppression among HIV people with opioid use disorder in Vietnam. The primary objective of this analysis was to evaluate associations between participant characteristics and the critical steps in the HIV care continuum of ART initiation and HIV viral suppression among people with opioid use disorder and HIV in Vietnam.

METHODS

We assessed baseline participant characteristics, ART status, and HIV viral suppression (HIV RNA PCR < 200 copies/mL) enrolled in a clinical trial of HIV clinic-based buprenorphine versus referral for methadone among people with opioid use disorder in Vietnam. We developed logistic regression models to identify characteristics associated with ART status and HIV viral suppression.

RESULTS

Among 283 study participants, 191 (67.5%) were prescribed ART at baseline, and 168 of those on ART (90%) were virally suppressed. Years since HIV diagnosis (aOR = 1.12, 95% CI 1.06, 1.19) and being married (aOR = 2.83, 95% CI 1.51, 5.34) were associated with an increased likelihood of current prescription for ART at baseline. Greater depression symptoms were negatively associated with receipt of ART (aOR = 0.97, 95% CI = (0.94, 0.9963)). In the HIV suppression model, once adjusting for all included covariates, only receipt of ART was associated with viral suppression (aOR = 25.9, 95% CI = (12.5, 53.8). In bivariate analyses, methamphetamine was negatively correlated with ART prescription (p = 0.07) and viral suppression (p = 0.08).

CONCLUSION

While fewer than 90% of participants had received ART, 90% of those on ART had achieved HIV viral suppression at baseline, suggesting that interventions to improve uptake of ART in Vietnam are essential for achieving UNAIDS 90-90-90 goals in people who use heroin in Vietnam. Social determinants of health associated with ART and HIV viral suppression suggest that social support may be a key to facilitating both of these steps in the HIV care continuum.

Patterns of alcohol use and associated characteristics and HIV-related outcomes among a sample of African-American women living with HIV

BACKGROUND

Alcohol use is common among people living with HIV and negatively impacts care and outcomes. African-American women living with HIV are subject to vulnerabilities that may increase risk for alcohol use and associated HIV-related outcomes.

METHODS

We used baseline data from a randomized controlled trial of an HIV-related stigma-reduction intervention among African-American women living with HIV in Chicago and Birmingham (2013-2015). Patterns of alcohol use [any use, unhealthy alcohol use (UAU), heavy episodic drinking (HED)] were measured using the AUDIT-C. We assessed demographic, social, and clinical characteristics which may influence alcohol use and HIV-related outcomes which may be influenced by patterns of alcohol use in bivariate and multivariable analyses.

RESULTS

Among 220 African-American women living with HIV, 54 % reported any alcohol use, 24 % reported UAU, and 27 % reported HED. In bivariate analysis, greater depressive symptoms, lower religiosity, lower social support, marijuana, and crack/cocaine use were associated with patterns of alcohol use (p < 0.05). Marijuana and cocaine/crack use were associated with patterns of alcohol use in adjusted analysis (p < 0.05). In adjusted analysis, any alcohol use and HED were associated with lower likelihood of ART adherence (ARR = 0.72, 95 % CI: 0.53-0.97 and ARR = 0.65, 95 % CI: 0.44-0.96, respectively), and UAU was associated with lack of viral suppression (ARR = 0.78, 95 % CI: 0.63-0.96).

CONCLUSIONS

Findings suggest any and unhealthy alcohol use is common and associated with poor HIV-related outcomes in this population. Regular alcohol screening and intervention should be offered, potentially targeted to subgroups (e.g., those with other substance use).

Neuroinvasion and cognitive impairment in comorbid alcohol dependence and chronic viral infection: An initial investigation

Viruses that invade the central nervous system (CNS) can cause neuropsychiatric impairments. Similarly, chronic alcohol exposure can induce inflammatory responses that alter brain function. However, the effects of a chronic viral infection and comorbid alcohol use on neuroinflammation and behavior are not well-defined. We investigated the role of heavy alcohol intake in regulating inflammatory responses and behavioral signs of cognitive impairments in mice infected with lymphocytic choriomeningitis virus (LCMV) clone 13. LCMV-infected mice exposed to alcohol had increased peripheral inflammation and impaired cognitive function (as indicated by performance on the novel object recognition test). Initial findings suggest that brain region-specific dysregulation of microglial response to viral infection may contribute to cognitive impairments in the context of heavy alcohol use.

A Digital Intervention Addressing Alcohol Use Problems (the "Daybreak" Program): Quasi-Experimental Randomized Controlled Trial

BACKGROUND

Alcohol use is prevalent in many societies and has major adverse impacts on health, but the availability of effective interventions limits treatment options for those who want assistance in changing their patterns of alcohol use.

OBJECTIVE

This study evaluated the new Daybreak program, which is accessible via mobile app and desktop and was developed by Hello Sunday Morning to support high-risk drinking individuals looking to change their relationship with alcohol. In particular, we compared the effect of adding online coaching via real-time chat messages (intervention group) to an otherwise self-guided program (control group).

METHODS

We designed the intervention as a randomized control trial, but as some people (n=48; 11.9%) in the control group were able to use the online coaching, the main analysis comprised all participants. We collected online surveys at one-month and three-months follow-up. The primary outcome was change in alcohol risk (measured with the alcohol use disorders identification test-consumption [AUDIT-C] score), but other outcomes included the number of standard drinks per week, alcohol-related days out of role, psychological distress (Kessler-10), and quality of life (EUROHIS-QOL). Markers of engagement with the program included posts to the site and comments on the posts of others. The primary analysis used Weighted Generalized Estimating Equations.

RESULTS

We recruited 398 people to the intervention group (50.2%) and 395 people to the control group (49.8%). Most were female (71%) and the mean age was 40.1 years. Most participants were classified as probably dependent (550, 69%) on the AUDIT-10, with 243 (31%) classified with hazardous or harmful consumption. We followed up with 334 (42.1%) participants at one month and 293 (36.9%) at three months. By three months there were significant improvements in AUDIT-C scores (down from mean 9.1 [SD 1.9] to 5.8 [SD 3.1]), alcohol consumed per week (down from mean 37.1 [SD 28.3] to mean 17.5 [SD 18.9]), days out of role (down from mean 1.6 [SD 3.6] to 0.5 [SD 1.6]), quality of life (up from 3.2 [SD 0.7] to 3.6 [SD 0.7]) and reduced distress (down from 24.8 [SD 7.0] to 19.0 [SD 6.6]). Accessing online coaching was not associated with improved outcomes, but engagement with the program (eg, posts and comments on the posts of others) were significantly associated with improvements (eg, in AUDIT-C, alcohol use and EUROHIS-QOL). Reduced alcohol use was found for both probably dependent (estimated marginal mean of 40.8 to 20.1 drinks) and hazardous or harmful alcohol users (estimated marginal mean of 22.9 to 11.9 drinks).

CONCLUSIONS

Clinically significant reductions in alcohol use were found, as well as reduced alcohol risk (AUDIT-C) and days out of role. Importantly, improved alcohol-related outcomes were found for both hazardous or harmful and probably dependent drinkers. Since October 2016, Daybreak has reached more than 50,000 participants. Therefore, there is the potential for the program to have an impact on alcohol-related problems at a population health level, importantly including an effect on probably dependent drinkers.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12618000010291; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373110.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/9982.

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).

Utility of routine alcohol screening for monitoring changes in alcohol consumption

BACKGROUND

Routine alcohol screening scores are increasingly available in electronic health records (EHRs). Changes in such scores could be useful for monitoring response to brief intervention or treatment of alcohol use disorder. However, it is unclear whether changes in clinically-documented AUDIT-C alcohol screening scores reflect true changes in drinking. This study evaluated associations between changes in EHR AUDIT-C scores and changes in high density lipoprotein cholesterol (HDL), a laboratory test that reflects average alcohol consumption.

METHODS

National U.S. Veterans Affairs EHR data (2004-2007) were used to identify patients screened with the AUDIT-C (0-12 points), on two occasions at least a year apart, who had HDL measured in the year after each screen. First differencing linear regression estimated associations between changes in AUDIT-C score (-12 to 12 points; modeled categorically to allow for non-linear associations) and subsequent changes in HDL (mg/dL), adjusting for baseline HDL. Additional analyses evaluated whether associations between changes in AUDIT-C and changes in HDL were modified by baseline AUDIT-C.

RESULTS

Among 316,712 patients, increases-but not decreases-in AUDIT-C scores were associated with commensurate changes in HDL. However, a significant interaction was observed with baseline AUDIT-C score (p < 0.00001), which revealed that decreases in AUDIT-C scores were also associated with commensurate decreases in HDL (p-values<0.05) except among the 1.5% of patients with the highest baseline AUDIT-C scores (10-12).

CONCLUSIONS

Findings suggest that changes in EHR AUDIT-C scores reflect changes in drinking. These results support the use of clinically-documented alcohol screening scores for monitoring patients' alcohol use over time.

HIV-Related Stigma and Viral Suppression Among African-American Women: Exploring the Mediating Roles of Depression and ART Nonadherence

We used baseline data from a sample of African-American women living with HIV who were recruited to participate in a stigma-reduction intervention in Chicago and Birmingham (2013-2015) to (1) evaluate the relationship between HIV-related stigma and viral suppression, and (2) assess the role of depression and nonadherence to antiretroviral therapy (ART) as mediators. Data from women were included in this secondary analysis if they were on ART, had viral load data collected within 8-weeks of study entry and had complete covariate data. We used logistic regression to estimate the total effect of HIV-related stigma (14-item Stigma Scale for Chronic Illness) on viral suppression (< 200 copies/mL), and serial mediation analysis to estimate indirect effects mediated by depressive symptoms (8-item Patient Health Questionnaire) and ART nonadherence (number of days with missed doses). Among 100 women who met study inclusion criteria, 95% reported some level of HIV-related stigma. In adjusted models, higher levels of HIV-related stigma were associated with lower odds of being virally suppressed (AOR = 0.93, 95% CI = 0.89-0.98). In mediation analysis, indirect effects through depression and ART nonadherence were not significant. Findings suggest that HIV-related stigma is common among African-American women living with HIV, and those who experience higher levels of stigma are less likely to be virally suppressed. However, the mechanisms remain unclear.

Reduction in non-abstinent WHO drinking risk levels and depression/anxiety disorders: 3-year follow-up results in the US general population

BACKGROUND

Non-abstinent drinking reductions that predict improvement in how individuals feel or function, such as the World Health Organization (WHO) drinking risk levels, may be useful outcomes in clinical trials for alcohol use disorders (AUD).

METHODS

Current drinkers in a U.S. national survey (n = 22,005) were interviewed in 2001-02 (Wave 1) and re-interviewed 3 years later (Wave 2). WHO drinking risk levels, a 4- level categorization system (very-high-risk, high-risk, moderate-risk, and low-risk drinkers) defined using estimated mean ethanol consumption (grams) per day in the prior 12 months, and DSM-IV depressive and anxiety disorders were assessed at both waves. Logistic regression was used to produce adjusted odds ratios (aOR) testing the associations of changes between Wave 1 and Wave 2 WHO risk levels to the presence or persistence of depression and/or anxiety disorder by each initial Wave 1 risk level.

RESULTS

Among Wave 1 very-high-risk drinkers, lower odds of depression and/or anxiety disorders at Wave 2 were predicted by reductions in WHO risk levels of one-, two- or three-levels (aOR = 0.42, 0.37, 0.67, p-values 0.04-<.0001), as was the persistence of depression and/or anxiety disorders among those with such disorders at Wave 1 (aOR = 0.37, 0.29, 0.51, p-values .03-<.0001). Results were less consistent for participants initially drinking at lower risk levels.

CONCLUSIONS

Among very-high-risk drinkers, reductions in the WHO drinking risk categories were associated with lower risk of depression and/or anxiety disorders. These results add to findings indicating reductions in WHO risk levels are a meaningful indicator of how individuals feel and function.

Sex differences in the association between impulsivity and driving under the influence of alcohol in young adults: The specific role of sensation seeking

INTRODUCTION

There is an outstanding need to identify predictors of driving under the influence of alcohol (DUI) among young adults, particularly women. Impulsivity, or the tendency to act without thinking, is a predictor of DUI, but the specific facets of impulsivity that predict DUI and their interaction with sex differences remain unclear. We aimed to investigate sex differences in the link between impulsivity facets and DUI. Moreover, we sought to replicate previous findings regarding sex differences on impulsivity, and associations between impulsivity facets and DUI.

METHOD

A total of 506 university students participated in the study (males, n = 128; females, n = 378). Participants completed measures of impulsivity (UPPS-P short version), alcohol use (AUDIT-C), frequency of DUI episodes and related perception of risk. The UPPS-P assesses five facets of impulsivity: sensation seeking, (lack of) premeditation and perseverance and positive and negative urgency.

RESULTS

Men showed higher sensation seeking and lack of perseverance, alcohol use and DUI frequency and lower risk perception than women. DUI frequency was negatively associated with perception of risk and positively associated with alcohol use and the five impulsivity facets. After controlling for alcohol use and risk perception, only lack of premeditation was associated with DUI frequency in the whole sample. Sensation seeking was positively associated with DUI frequency only in women.

DISCUSSION

The link between lack of premeditation and DUI suggest that pre-drinking planning strategies can contribute to prevent risky driving. In women, specific links between sensation seeking and DUI suggest the need for personality-tailored prevention strategies.

Reduction in Nonabstinent WHO Drinking Risk Levels and Change in Risk for Liver Disease and Positive AUDIT-C Scores: Prospective 3-Year Follow-Up Results in the U.S. General Population

BACKGROUND

Abstinence is often the treatment aim for alcohol use disorders (AUD), but this may deter individuals who prefer drinking reduction goals from entering treatment, and be an overly restrictive end point in alcohol clinical trials. Nonabstinent drinking reductions that predict improvement in how individuals feel or function may be useful clinical trial outcomes, for example, reductions in the 4-category World Health Organization (WHO) drinking risk levels. To investigate the clinical relevance of these reductions, we examined their relationship with 2 outcomes of interest to medical providers: liver disease, and positive scores on an alcohol screening measure.

METHODS

Current drinkers in a U.S. national survey (n = 21,925) were interviewed in 2001 to 2002 (Wave 1) and re-interviewed 3 years later (Wave 2). WHO drinking risk levels, liver disease, and the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) were assessed at both waves. Adjusted odds ratios (aORs) were used to indicate the association of change in WHO drinking risk levels with Wave 2 liver disease and AUDIT-C scores.

RESULTS

Wave 1 very-high-risk drinkers who reduced 1, 2, or 3 WHO drinking risk levels had significantly lower odds of Wave 2 liver disease (aORs = 0.34, 0.23, 0.17) and positive AUDIT-C scores (aORs = 0.27, 0.09, 0.03). Wave 1 high-risk drinkers who reduced 1 or 2 WHO risk levels had significantly lower odds of positive AUDIT-C scores (aORs = 0.61, 0.25). Adjusting for alcohol dependence or AUDIT-C scoring variations did not affect results.

CONCLUSIONS

In the highest-risk drinkers, reductions in WHO drinking risk levels predicted lower likelihood of liver disease and positive AUDIT-C scores. Results add to findings that reductions in the 4-category WHO drinking risk levels are a meaningful indicator of how individuals feel and function, and could serve as nonabstinent end points in clinical trials. Results also connect the WHO risk drinking levels to commonly used alcohol screening questions, which may be more familiar to healthcare providers.

Comparing short versions of the Alcohol Use Disorders Identification Test (AUDIT) in a military cohort

Background

The Alcohol Use Disorders Identification Test (AUDIT) is widely used for monitoring harmful alcohol consumption among high-risk populations. A number of short versions of AUDIT have been developed for use in time-constrained settings. In military populations, a range of AUDIT variations have been used, but the optimal combination of AUDIT items has not been determined.

Methods

A total of 952 participants (80% male), recruited as part of a wider study, completed the AUDIT-10. We systematically assessed all possible combinations of three or four AUDIT items and established AUDIT variations using the following statistics: Cronbach’s alpha (internal consistency), variance explained (R2) and Pearson’s correlation coefficient (concurrent validity).

Results

Median AUDIT-10 score was 7 for males and 6 for females, and 380 (40%) participants were classified as having a score indicative of harmful or hazardous alcohol use (≥8) according to WHO classifications.

A novel four-item AUDIT variation (3, 4, 8 and 9) performed consistently higher than established variations across statistical measures; it explained 85% of variance in AUDIT-10, had a Pearson’s correlation of 0.92 and Cronbach’s alpha was 0.63. The FAST, an established shortened AUDIT variant, together with several other four-item novel variants of AUDIT-10 performed similarly. The AUDIT-C performed consistently low on all measures, but with a satisfactory level of internal consistency (75%).

Conclusion

Shortened AUDIT variations may be suitable alternatives to the full AUDIT for screening hazardous alcohol consumption in military populations. Four-item AUDIT variations focused on short-term risky drinking and its consequences performed better than three item versions.

Trial registration number

ACTRN12614001332617.

Changes in alcohol use associated with changes in HIV disease severity over time: A national longitudinal study in the Veterans Aging Cohort

BACKGROUND

Among groups of persons living with HIV (PLWH), high-risk drinking trajectories are associated with HIV severity. Whether changes in individuals' alcohol use are associated with changes in HIV severity over the same period is unknown.

METHODS

Veterans Aging Cohort Study (VACS) data from VA's EHR (2/1/2008-9/30/2016) identified AUDIT-C screens for all PLWH. Pairs of AUDIT-C screens within 9-15 months were included if CD4 and/or viral load (VL) was measured within 9 months after baseline and follow-up AUDIT-Cs. Linear regression assessed change in HIV severity (CD4 and logVL) associated with AUDIT-C change adjusted for confounders. Mean changes in HIV severity were estimated for each AUDIT-C change value. For all measures of change, positive values indicate improvements (lower drinking and improved HIV severity).

RESULTS

Among PLWH, 21,999 and 22,143 were eligible for CD4 and VL analyses, respectively. Most had non- or low-level drinking and stable consumption over time (mean AUDIT-C change = .08, SD = 1.91). HIV severity improved over time [mean CD4 change = 20.5 (SD 180.8); mean logVL change = 0.12 (SD 0.71)]. AUDIT-C changes were associated non-linearly with changes in CD4 (p = 0.03) and logVL (p < 0.001). Improvement in HIV severity was greatest among those with stable AUDIT-C scores over time; those with greater AUDIT-C increases fared worse than those with smaller increases in or stable AUDIT-Cs.

CONCLUSIONS

Improvement in HIV severity was greatest among PLWH with relatively stable drinking, most of whom initially did not drink or drank at low levels. Those with large changes (especially increases) in drinking appear at greatest risk for poor HIV control.

A Participatory Health Promotion Mobile App Addressing Alcohol Use Problems (The Daybreak Program): Protocol for a Randomized Controlled Trial

Background

At-risk patterns of alcohol use are prevalent in many countries with significant costs to individuals, families, and society. Screening and brief interventions, including with Web delivery, are effective but with limited translation into practice to date. Previous observational studies of the Hello Sunday Morning approach have found that their unique Web-based participatory health communication method has resulted in a reduction of at-risk alcohol use between baseline and 3 months. The Hello Sunday Morning blog program asks participants to publicly set a personal goal to stop drinking or reduce their consumption for a set period of time, and to record their reflections and progress on blogs and social networks. Daybreak is Hello Sunday Morning’s evidence-based behavior change program, which is designed to support people looking to change their relationship with alcohol.

Objective

This study aims to systematically evaluate different versions of Hello Sunday Morning’s Daybreak program (with and without coaching support) in reducing at-risk alcohol use.

Methods

We will use a between groups randomized control design. New participants enrolling in the Daybreak program will be eligible to be randomized to receive either (1) the Daybreak program, including peer support plus behavioral experiments (these encourage and guide participants in developing new skills in the areas of mindfulness, connectedness, resilience, situational strategies, and health), or (2) the Daybreak program, including the same peer support plus behavioral experiments, but with online coaching support. We will recruit 467 people per group to detect an effect size of f=0.10. To be eligible, participants must be resident in Australia, aged ≥18 years, score ≥8 on the alcohol use disorders identification test (AUDIT), and not report prior treatment for cardiovascular disease.

Results

The primary outcome measure will be reduction in the AUDIT-Consumption (AUDIT-C) scores. Secondary outcomes include mental health (Kessler’s K-10), days out of role (Kessler), alcohol consumed (measured with a 7-day drinking diary in standard 10 g drinks), and alcohol-related harms (CORE alcohol and drug survey). We will collect data at baseline and 1, 3, and 6 months and analyze them with random effects models, given the correlated data structure.

Conclusions

A randomized trial is required to provide robust evidence of the impact of the online coaching component of the Daybreak program, including over an extended period.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618000010291; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373110 (Archived by WebCite at http://www.webcitation.org/6zKRmp0aC)

Registered Report Identifier

RR1-10.2196/9982

Alcohol Consumption Reduction Among a Web-Based Supportive Community Using the Hello Sunday Morning Blog Platform: Observational Study

BACKGROUND

Alcohol misuse is a major social and public health issue in Australia, with an estimated cost to the community of Aus $30 billion per annum. Until recently, a major barrier in addressing this significant public health issue is the fact that the majority of individuals with alcohol use disorders and alcohol misuse are not receiving treatment.

OBJECTIVE

This study aimed to assess whether alcohol consumption changes are associated with participation in Hello Sunday Morning's blog platform, an online forum discussing experiences in abstaining from alcohol.

METHODS

The study reports on Hello Sunday Morning participants who signed up for a 3-month period of abstinence from November 2009 to November 2016. The sample comprised 1917 participants (female: 1227/1917, 64.01%; male: 690/1917, 35.99%). Main outcome measures were Alcohol Use Disorders Identification Test (AUDIT) scores, mood, program engagement metrics, and slip-ups.

RESULTS

Individuals who reported hazardous (preprogram AUDIT mean 11.92, SD 2.25) and harmful consumption levels (preprogram AUDIT mean 17.52, SD 1.08) and who engaged in the Hello Sunday Morning program reported a significant decrease in alcohol consumption, moving to lower risk consumption levels (hazardous, mean 7.59, SD 5.70 and harmful, mean 10.38, SD 7.43), 4 months following program commencement (P<.001). Those who reported high-risk or dependent consumption levels experienced the biggest reduction (preprogram mean 25.38, SD 4.20), moving to risky consumption (mean 15.83, SD 11.11), 4 months following program commencement (P<.001). These reductions in risk were maintained by participants in each group, 7 months following program commencement. Furthermore, those who engaged in the program more (as defined by more sign-ins, blogs posted, check-ins completed, and engagement with the community through likes and following) had lower alcohol consumption. Finally, those who experienced more slip-ups had lower alcohol consumption.

CONCLUSIONS

Participation in an online forum can support long-term behavior change in individuals wishing to change their drinking behavior. Importantly, reductions in AUDIT scores appeared larger for those drinking at high-risk and hazardous levels before program commencement. This has promising implications for future models of alcohol reduction treatment, as online forums are an anonymous, accessible, and cost-effective alternative or adjunct to treatment-as-usual. Further research is needed into the specific mechanisms of change within a Web-based supportive community, as well as the role of specific mood states in predicting risky drinking behavior.

Outcome of day treatment for older adults with affective disorders: An observational pre-post design of two transdiagnostic approaches

OBJECTIVE

First, to evaluate the outcome of 2 transdiagnostic day treatment programs. A 20-week psychotherapeutic day treatment (PDT) and an activating day treatment (ADT) program delivered in blocks of 4 weeks with a maximum of 24 weeks with respect to depression, anxiety, and hypochondriasis. Second, to explore the impact of cognitive impairment and personality pathology on treatment outcome.

METHODS

The course of depression (Inventory of Depressive Symptoms), anxiety (Geriatric Anxiety Inventory), and hypochondriasis (Whitley Index) were evaluated by linear mixed models adjusted for age, sex, level of education, and alcohol usage among 49 patients (mean age 65 years, 67% females) receiving PDT and among 61 patients (mean age 67.1, 61% females) receiving ADT. Pre-post effect-sizes were expressed as Cohen's d. Subsequently, cognitive impairment (no, suspected, established) and personality pathology (DSM-IV criteria as well as the Big Five personality traits) were examined as potential moderators of treatment outcome.

RESULTS

Among patients receiving PDT, large improvements were found for depression (d = 1.1) and anxiety (d = 1.2) but not for hypochondriasis (d = 0.0). Patients receiving ADT showed moderate treatment effects for depression (d = 0.6), anxiety (d = 0.6), as well as hypochondriasis (d = 0.6). Personality pathology moderates treatment outcome of neither PDT nor ADT. Cognitive impairment negatively interfered with the course of depressive symptoms among patients receiving PDT.

CONCLUSIONS

Transdiagnostic day treatment is promising for older adults with affective disorders with high feasibility.

Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary CarE (CHOICE) trial

BACKGROUND

Most patients with alcohol use disorders (AUDs) never receive alcohol treatment, and experts have recommended management of AUDs in primary care. The Choosing Healthier Drinking Options In primary CarE (CHOICE) trial was a randomized controlled effectiveness trial of a novel intervention for primary care patients at high risk for AUDs. This report describes the conceptual and scientific foundation of the CHOICE model of care, critical elements of the CHOICE trial design consistent with the Template for Intervention Description and Replication (TIDieR), results of recruitment, and baseline characteristics of the enrolled sample.

METHODS

The CHOICE intervention is a multi-contact, extended counseling intervention, based on the Chronic Care Model, shared decision-making, motivational interviewing, and evidence-based options for managing AUDs, designed to be practical in primary care. Outpatients who received care at 3 Veterans Affairs primary care sites in the Pacific Northwest and reported frequent heavy drinking (≥4 drinks/day for women; ≥5 for men) were recruited (2011-2014) into a trial in which half of the participants would be offered additional alcohol-related care from a nurse. CHOICE nurses offered 12 months of patient-centered care, including proactive outreach and engagement, repeated brief motivational interventions, monitoring with and without alcohol biomarkers, medications for AUDs, and/or specialty alcohol treatment as appropriate and per patient preference. A CHOICE nurse practitioner was available to prescribe medications for AUDs.

RESULTS

A total of 304 patients consented to participate in the CHOICE trial. Among consenting participants, 90% were men, the mean age was 51 (range 22-75), and most met DSM-IV criteria for alcohol abuse (14%) or dependence (59%). Many participants also screened positive for tobacco use (44%), depression (45%), anxiety disorders (30-41%) and non-tobacco drug use disorders (19%). At baseline, participants had a median AUDIT score of 18 [Interquartile range (IQR) 14-24] and a median readiness to change drinking score of 5 (IQR 2.75-6.25) on a 1-10 Likert scale.

CONCLUSION

The CHOICE trial tested a patient-centered intervention for AUDs and recruited primary care patients at high risk for AUDs, with a spectrum of severity, co-morbidity, and readiness to change drinking. Trial registration The trial is registered at clinicaltrial.gov (NCT01400581).

Prevalence of alcohol use disorders among under- and post-graduate healthcare students in Italy

A cross-sectional study was carried out on 641 medical students, 359 students attending a degree course in the healthcare professions, and 500 resident physicians, all undergoing health surveillance at the ambulatory of the Division of Occupational Medicine, Second University of Naples, Italy. 76.1% of the participants drank alcohol, with 85.5% of medical students, 77.4% of resident physicians, and 63% of healthcare-professions students reporting regular alcohol use. In the whole sample, the mean Audit-C score was 1.6 for men and 1.1 for women; only 5.5% of men and 7.1% of women had a hazardous alcohol consumption with an Audit-C score of respectively ≥4 and ≥3. Multivariate regression modeling revealed that regular alcohol use was more likely in individuals who were men, were younger, had a lower body-mass index, were active smokers, were habitual coffee drinkers, and who were resident physicians or medical students rather than healthcare-professions students. This finding identifies a need to assess alcohol use in medical-profession workers in order to identify risky behavior early on and to carry out rapidly effective preventive and curative interventions.

Documented brief intervention not associated with resolution of unhealthy alcohol use one year later among VA patients living with HIV

OBJECTIVE

Unhealthy alcohol use is particularly risky for patients living with HIV (PLWH). Brief interventions reduce drinking among patients with unhealthy alcohol use, but whether its receipt in routine outpatient settings is associated with reduced drinking among PLWH with unhealthy alcohol use is unknown. We assessed whether PLWH who screened positive for unhealthy alcohol use were more likely to resolve unhealthy drinking one year later if they had brief alcohol intervention (BI) documented in their electronic health record in a national sample of PLWH from the Veterans Health Administration.

METHODS

Secondary VA clinical and administrative data from the electronic medical record (EMR) were used to identify all positive alcohol screens (AUDIT-C score≥5) documented among PLWH (10/01/09-5/30/13) followed by another alcohol screen documented 9-15months later. Unadjusted and adjusted Poisson regression models assessed the association between brief intervention (advice to reduce drinking or abstain documented in EMR) and resolution of unhealthy alcohol use (follow-up AUDIT-C<5 with ≥2 point reduction).

RESULTS

Overall 2101 PLWH with unhealthy drinking (10/01/09-5/30/13) had repeat alcohol screens 9-15months later. Of those, 77% had brief intervention documented after their first screen, and 61% resolved unhealthy alcohol use at follow-up. Documented brief intervention was not associated with resolution [Adjusted incidence rate ratio 0.96, (95% CI 0.90-1.02)].

CONCLUSIONS

Documented brief intervention was not associated with resolving unhealthy alcohol use at follow-up screening among VA PLWH with unhealthy alcohol use. Effective methods of resolving unhealthy alcohol use in this vulnerable population are needed.