Lead/Presenter: Dan Blalock, COIN - Durham
All Authors: Blalock DV (Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham NC; Dept), Smith VA (Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham NC; Department of Population Health Sciences, Duke University, Durham NC) Berlin SA (Institute for Medical Research, Durham NC) Berkowitz T (Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham NC) Grubber J (Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham NC)
The co-occurrence of alcohol misuse and opioid misuse is high and associated with increased rates of overdose, emergency healthcare utilization, and death. Veterans represent an especially vulnerable group for opioid overdose and death, due to the increased prevalence of both opioid misuse and alcohol misuse in this population. Veterans Health Administration (VHA) has the longest existing infrastructure of screening and brief intervention for alcohol misuse (SBI), which is a CDC-recommended strategy in opioid-using populations for decreasing opioid overdose deaths. The objective of this investigation was to examine whether VHAâ€™s alcohol-related SBI reduces the risk of later opioid-related outcomes.
This study was a retrospective cohort study of 489,871 Veterans who have had at least one recorded Alcohol Use Disorders Identification Test â€“ Consumption (AUDIT-C) score within the Veterans Integrated Service Network (VISN) 6 VHA between Jan 1, 2014 and Dec 31, 2019. Existing electronic medical records (EMR) data were pulled from the VHAâ€™s Corporate Data Warehouse (CDW), including open text Health Factors, AUDIT-C scores, opioid prescriptions, opioid use disorder (OUD) diagnosis, and opioid-related hospitalizations. Demographic and clinical covariates were also pulled and constructed, including age, gender, race, ethnicity, marital status, service connection, other substance use and mental health disorders, and NOSOS risk score for VA utilization cost. Index AUDIT-C was defined as the first, if exists, â€œpositiveâ€ (> = 5) AUDIT-C, otherwise the highest ( < 5) AUDIT-C in the observation window. Open text Health Factors were individually content coded for alcohol-related SBI and classified as "positive" if present in days 1 to 14 post-Index AUDIT-C. Opioid-related outcomes were restricted to an observation period between 14 days post-index AUDIT-C and 1-year post-index AUDIT-C. Opioid prescriptions and OUD diagnoses were not considered a new opioid-related outcome if they were documented in the year prior to the index AUDIT-C.
Thirteen percent (N = 64,005) of Veterans had â€œpositiveâ€ AUDIT-C values > = 5. Of those Veterans, 72% (N = 46,363) had documented alcohol-related SBI in the requisite 14-day window. In the year following index AUDIT-C, Veterans with â€œpositiveâ€ AUDIT-C values that did not receive alcohol-related SBI had higher odds of new opioid prescriptions (OR = 1.12, 95%C.I.[1.04,1.21]), new OUD diagnoses (OR = 1.20, 95%C.I.[1.04,1.39]), and new opioid-related hospitalizations (OR = 1.20, 95%C.I.[1.00,1.45]) than Veterans with â€œpositiveâ€ AUDIT-C values that did receive alcohol-related SBI in adjusted models. These associations were all statistically significant in unadjusted models.
VHAâ€™s standard alcohol-related SBI is associated with subsequent lower odds of a cascade of opioid-related outcomes, even after controlling for numerous other demographic and clinical factors associated with opioid use and harm.
VHAâ€™s robust alcohol-related SBI may have important benefits to Veterans outside of reducing harm associations with alcohol misuse, specifically in the high priority area of opioid misuse and associated emergency healthcare utilization. Additionally, VHAâ€™s Stratification Tool for Opioid Risk Mitigation (STORM) may benefit from considering inclusion of AUDIT-C screening information and alcohol-related SBI information in its algorithm, which currently only includes documented Alcohol Use Disorder diagnosis.