unhealthy alcohol use in other drug users identified by screening in primary care secondary analysis...

Unhealthy alcohol use in other drug users identified by

screening in primary care

Secondary analysis of ASPIRE trial dataFunded by NIDA 1 R01 DA025068with support from SAMHSA. Clinicaltrials.gov ID NCT00876941

Christine Maynié-François

Debbie Cheng

Jeffrey Samet

Christine Lloyd-Travaglini

Tibor Palfai

Judith Bernstein

Richard Saitz

Background Alcohol use common in other drug users Negative impact on

Other drug useAlcohol and other drug (AOD) use

consequences (unsafe sex, injury, fatal overdoses)

Most studies on patients in substance abuse treatment, community

Few data on primary care patients, identified by screening

Aims Primary: Describe alcohol use in patients

screening positive for other drug use in primary care

Secondary: Evaluate the association between unhealthy alcohol use andOther drug useAOD-use related consequences

Hypothesis

In this primary care cohort of patients screening positive for drug use, there will be an association between unhealthy alcohol use and drug use/consequences.

Methods Cross-sectional design Secondary analysis Cohort recruited by systematic screening in

primary care for randomized controlled trial (ASPIRE study)

Main eligibility criteria : ASSIST drug-specific score ≥2 (once or twice over past 3 months)

ASPIRE = Assessing Screening Plus brief Intervention’s Resulting Efficacy to stop drug use.

ASSIST = Alcohol, Smoking and Substance Involvement Screening Test

Predictors: unhealthy alcohol use

Any past month heavy drinking day (HDD) (≥4♀ or ≥5♂ drinks in a day)

Primary

Number of past month HDDNone / 1-4 / >4

Secondary Secondary

AUDIT-C score (past year)

0 = abstinent1- 2/3 (♀/♂) = low-risk 3/4 - 9 (♀/♂) = risky use10+ = probable dependence

AUDIT-C = Alcohol Use Disorder Identification Test – Consumption

Outcomes: other drug use and AOD use related consequences

Past month # days use Drug Of Most Concern = DOMC (determined by patient)

Primary

Past 3 months:-Injection drug use -Use of more than one drug- Any drug dependence (ASSIST 27+)

Secondary: Use Secondary: Consequences

Past 3 months:-Drug use related problems (SIP-D score)-Unsafe sex -Injury-Arrest/incarceration

ASSIST = Alcohol, Smoking and Substance Involvement Screening TestSIP-D = Short Inventory of Problems - Drugs

Analysis

Negative binomial regression models for count outcomes

Logistic regression models for binary outcomes

Adjusted for Demographics : age, sex, race/ethnicity, employment,

homelessness, partner, children Psychiatric co morbidity: PHQ-9 (depression

symptoms)

PHQ-9 = Patient Health Questionnaire 9 items

Demographics

Demographics, N=589

Age , mean (SD) 41 (4)

Male 68 %

Race/ethnicty

Black or African-American 63 %

Hispanic or Latino 11 %

White 20 %

1+ night on the street or in shelter (past 3 months) 16 %

Unemployed 72 %

Alcohol use

Heavy drinking day = ≥4♀ or ≥5♂ drinks in a dayAUDIT-C = Alcohol Use Disorder Identification Test – ConsumptionDOMC = Drug Of Most Concern

Heavy drinking days (past month), N=589

Any past month heavy drinking day 48 %

# HDD among heavy drinkers, mean (SD) 9 (9)

AUDIT-C score (past year)

AUDIT-C 0 (abstinence) 11 %

AUDIT-C 1 – 2/3 (♀/♂) (low risk use) 26 %

AUDIT-C 3/4 – 9 (♀/♂) (risky use) 44 %AUDIT-C 10+ (probable dependence) 19 %

Other drug use

Other drug use, N=589Past month # days use Drug Of Most Concern, mean (SD)

12 (13)

Marijuana as DOMC 63 %

Opioids as DOMC 16 %

Cocaine as DOMC 18 %

Injection Drug Use (past 3 months) 11 %

Use of more than one drug (past 3 months) 31 %

Any drug dependence ASSIST 27+ (past 3 months) 16 %

DOMC = Drug Of Most Concern

ASSIST = Alcohol, Smoking and Substance Involvement Screening Test

AOD use related consequences (past 3 months), N=589

Drug use related problems (SIP-D), mean (SD) 13 (11)

Any unsafe sex 51 %

# of times unsafe sex, mean (SD) 16 (39)

Any injury 15 %

Of those, injuries with alc/drg 2 hours prior 51 %

Any arrest / incarceration 6 %

Alcohol and Other Drug use related consequences

SIP-D = Short Inventory of Problems - Drugs

Primary predictor/ Primary outcome

# days use DOMC

Any heavy drinking day 1.00 [0.84-1.23]

DOMC = Drug Of Most ConcernResult given in adjusted IRR. Model adjusted for baseline covariates: age, sex, race/ethnicity, employment, tobacco use, homelessness, partner, children and PHQ-9.

Primary outcome Secondary predictors

# Days use DOMC

#HDD : 1-3 vs 0 0.96 [0.77-1.19]

#HDD : 4+ vs 0 1.05 [0.84-1.31]

AUDIT-C : 1-2/3 vs 0 0.95 [0.69-1.31]

AUDIT-C : 3/4 -9 vs 0 0.91 [0.67-1.23]

AUDIT-C : 10+ vs 0 0.78 [0.56-1.09]

HDD = Heavy Drinking DayAUDIT-C = Alcohol Use Disorder Identification Test – ConsumptionResults given in adjusted IRR. Model adjusted for baseline covariates: age, sex, race/ethnicity, employment, tobacco use, homelessness, partner, children and PHQ-9.

Secondary predictor #of heavy drinking days

More than 1 drug

Any drg dependce(ASSIST 27+)

#HDD 1-4 vs 0

1.65 [1.05-2.60]*

1.19 [0.65-2.20]

#HDD >4 vs 0

1.62 [1.02-2.58]*

2.48 [1.39-4.42]**

Any unsafe sex

# times unsafe sex

Any injury w/ AlcDrg 2 hours prior

Any arrest / incarceration

Drug related pbs

(SIP-D)

#HDD 1-4 vs 0

1.87 [1.12-3.12]*

1.33 [0.84-2.09]

1.16 [0.52-2.61]

0.98 [0.39-2.49]

1.10 [0.83-1.46]

#HDD >4 vs 0

1.93 [1.12-3.33]*

2.67 [1.62-4.39]**

2.22 [1.07-4.58]*

2.33 [1.06-5.11]*

1.87 [1.40-2.51]***

Results given in adjusted OR or IRR. Model adjusted for baseline covariates: age, sex, race/ethnicity, employment, tobacco use, homelessness, partner, children and PHQ-9. *p<0.05 **p<0,01 ***p<0.0001

No association found with- Injection Drug Use- Any injury

Primary predictor Secondary outcomes

More than 1 drug

Any drug dependence

(ASSIST 27+)

Any unsafe sex

# times unsafe sex

Drug use related pbs

(SIP-D)

Any heavy drinking day

1.64 [1.12-2.40]*

1.74 [1.06-2.84]*

1.90[1.24-2.90]**

1.87 [1.28-2.75]**

1.46 [1.15-1.85]**

Results given in adjusted OR or IRR. Model adjusted for baseline covariates: age, sex, race/ethnicity, employment, tobacco use, homelessness, partner, children and PHQ-9. *p<0.05 **p<0,01

No significant association with:- Injection Drug Use- Any injury- Any injury with Alcohol or Drug intake 2 hours prior- Any arrest or incarceration

Secondary predictor AUDIT-C score

Any drg dependce(ASSIST 27+)

# times unsafe sex Drug related pbs(SIP-D score)

AUDIT-C 1-2/3 vs 0 1.43 [0.56-3.69] 1.02 [0.52-1.99] 0.94 [0.62-1.42]

AUDIT-C 3/4-9 vs 0 1.26 [0.52-3.05] 1.40 [0.75-2.63] 1.07 [0.73-1.58]

AUDIT-C 10+ vs 0 3.79 [1.53-9.36]** 2.82 [1.36-5.81]** 1.94 [1.26-2.98]**


No significant association found with:- Injection Drug Use- Use of more than one drug- Any unsafe sex- Any injury (+ with Alcohol or Drug intake 2 hours prior)- Any arrest or incarceration

Summary of findings

Unhealthy alcohol use (UAU) common in patients screening positive for drug use in primary care.

Unable to detect an association between UAU and # days use DOMC (primary)

UAU associated with more severe other drug use and consequences.

More of these associations detected when using # of heavy drinking days as the marker for UAU

Limitations External validity out of urban hospital-based primary

care No reason to think that the association between unhealthy

alcohol use and outcomes wouldn’t be the same in other settings

Separate role of alcohol and other drugs uncertain on AOD use related consequences Role of alcohol on unsafe sex No exploration of synergistic effect

Implications

Attention should be given to unhealthy alcohol use in people identified as other drug users in primary care (screening?)

Past month heavy drinking days appear to be a useful marker for other drug use severity and consequences

Acknowledgements CARE Unit, Boston University, Boston Medical Center

Mentor : Dr Richard SaitzDebbie ChengChristine Lloyd-TravagliniJeffrey SametJudith BernsteinTibor Palfai

DemographicsDemographics, N=589

Age , mean (SD) 41 (4)

Male 68 %

Race/ethnicty

Black or African-American 63 %

Hispanic or Latino 11 %

White 20 %

1+ night on the street or in shelter (past 3 months) 16 %

Unemployed 72 %

Partner 57 %

Children 65 %

Stratification by DOMC

Bivariate analysis A few significant results with DOMC cocaine

1+ HDD / Any unsafe sexAUDIT-C score / ASSIST 27+

AUDIT-C / # days use DOMC:Opioids: with low risk / unhealthy alcohol use

(mean 10 days)Cocaine: with alcohol dependence (mean 8 days)MJ: with abstinence (mean 19 days)

Regression results: Primary predictor= Any heavy drinking day

IDU More than 1 drug ASSIST 27+


0.99 [0.55-1.76]

1.64 [1.12-2.40]*

1.74 [1.06-2.84]*

Any unsafe sex

# times unsafe sex

IRR

Any injury

Any injury w/ AlcDrg 2 hours prior


SIP-D score IRR


1.90[1.24-2.90]**

1.87 [1.28-2.75]**

0.91 [0.57-1.47]

1.64 [0.87-3.08]

1.59 [0.79-3.19]

1.46 [1.15-1.85]**


Regression results: Second. predictor= Number of heavy drinking days


#HDD 1-4 vs 0

0.75 [0.36-1.57]

1.65 [1.05-2.60]*

1.19 [0.65-2.20]

#HDD >4 vs 0

1.33 [0.64-2.74]

1.62 [1.02-2.58]*

2.48 [1.39-4.42]**

Any unsafe sex

# times unsafe sex

Any injury Any injury w/ AlcDrg 2 hours prior


SIP-D score

#HDD 1-4 vs 0

1.87 [1.12-3.12]*

1.33 [0.84-2.09]

0.71 [0.38-1.31]

1.16 [0.52-2.61]

0.98 [0.39-2.49]

1.10 [0.83-1.46]

#HDD >4 vs 0

1.93 [1.12-3.33]*

2.67 [1.62-4.39]**

1.16 [0.66-2.03]

2.22 [1.07-4.58]*

2.33 [1.06-5.11]*

1.87 [1.40-2.51]***

Results given in adjusted OR or IRR. Model adjusted for baseline covariates: age, sex, race/ethnicity, employment, tobacco use, homelessness, partner, children and PHQ-9. *p<0.05 **p<0,01 ***p<0.0001

Regression results: Second.predictor = AUDIT-C score


AUDIT-C < 3/4 vs 0 1.45 [0.52-4.04] 0.86 [0.43-1.72] 1.43 [0.56-3.69]

AUDIT-C 3/4+ vs 0 1.43 [0.56-3.67] 1.35 [0.72-2.53] 1.26 [0.52-3.05]

AUDIT-C 10+ vs 0 2.00 [0.70-5.75] 1.49 [0.75-2.96] 3.79 [1.53-9.36]**

Any unsafe sex

# times unsafe sex

Any injury Any injury w/ AlcDrg 2 hours prior


SIP-D score

AUDIT-C< 3/4 vs 0

0.98 [0.46-2.05]

1.02 [0.52-1.99]

1.02 [0.42-2.46]

0.60 [0.19-1.86]

0.78 [0.18-3.46]

0.94 [0.62-1.42]

AUDIT-C3/4+ vs 0

1.67 [0.83-3.38]

1.40 [0.75-2.63]

0.85 [0.37-1.97]

0.57 [0.20-1.62]

1.26 [0.33-4.78]

1.07 [0.73-1.58]

AUDIT-C10+ vs 0

1.73 [0.78-3.83]

2.82 [1.36-5.81]**

1.00 [0.41-2.46]

1.57 [0.56-4.40]

2.54 [0.66-9.76]

1.94 [1.26-2.98]**


unhealthy alcohol use in other drug users identified by screening in primary care secondary analysis...

Documents