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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
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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
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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
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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.
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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
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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
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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
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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
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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 %
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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 %
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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
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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
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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.
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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.
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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
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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
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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]**
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 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
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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
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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
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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
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Acknowledgements CARE Unit, Boston University, Boston Medical Center
Mentor : Dr Richard SaitzDebbie ChengChristine Lloyd-TravagliniJeffrey SametJudith BernsteinTibor Palfai
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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 %
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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)
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Regression results: Primary predictor= Any heavy drinking day
IDU More than 1 drug ASSIST 27+
Any heavy drinking day
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
Any arrest / incarceration
SIP-D score IRR
Any heavy drinking day
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]**
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
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Regression results: Second. predictor= Number of heavy drinking days
IDU More than 1 drug ASSIST 27+
#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
Any arrest / incarceration
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
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Regression results: Second.predictor = AUDIT-C score
IDU More than 1 drug ASSIST 27+
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
Any arrest / incarceration
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]**
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