Are PTSD symptoms associated with engagement and response to alcohol care management for Veteran Affairs patients with high risk drinking?

Thesis (Master's)--University of Washington, 2017-06Introduction: Posttraumatic stress disorder (PTSD) may create important barriers to engagement in alcohol use disorder (AUD) care management. Among a sample of Veteran Affairs (VA) patients randomized to receive nurse care management for AUD, this study tested whether PTSD interfered with engagement in AUD care management and predicted more heavy drinking days at 12-month follow up than not having PTSD. Methods: VA patients from three primary care sites were enrolled in the Choosing Healthier Drinking Options In Primary Care (CHOICE) trial if they reported high-risk drinking (≥4 drinks/day for women; ≥5 for men, two times per week or once per week if any prior AUD treatment) and met eligibility criteria. This observational substudy was interested only in patients randomized to receive AUD care management and who completed baseline screening for PTSD (n=147). Adjusted generalized linear regression models with Poisson and binomial distributions were used to assess the relationship between baseline PTSD and the number of nurse care visits at 12 month follow up as well as the number of heavy drinking days in past 28 days at 12 month follow up, respectively. Results: Participants with and without PTSD did not differ significantly on baseline sociodemographic characteristics or baseline percent heavy drinking days. After adjusting for potential confounders, PTSD was not significantly associated with the number of visits with the CHOICE nurse. Participants with PTSD had significantly lower odds of having a heavy drinking day than patients without PTSD (OR=.77; 95% CI: .65, .92; p<.01). Conclusions: Findings suggest future interventions for AUD should not exclude patients with PTSD or dissuade providers from treating patients with high-risk drinking on the basis of having PTSD

Evaluation of Screening, Assessment, Diagnosis and Treatment for Cannabis Use Disorder in Primary Care

Thesis (Ph.D.)--University of Washington, 2022Nearly 50 million people use cannabis in the past year, and of those, 23% use cannabis daily. Frequent cannabis use increases risk of developing a cannabis use disorder (CUD), a problematic pattern of cannabis use leading to clinically significant impairment and distress. Primary care providers are ideally positioned to identify cannabis use and use disorders, provide brief interventions, and guide patients to treatment. However, CUD is under-recognized and undertreated in primary care settings. One key barrier is a lack of validated screening and assessment tools that are feasible and appropriate to use routinely in primary care. Specific aims of this dissertation were to: 1) test the performance of a single-item screening measure of patient-reported cannabis use compared to a gold-standard diagnostic criterion of Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5) CUD; 2) test the psychometric properties of a Substance Use Symptom Checklist; and 3) test whether the probability of clinically recognized CUD and treatment increases with greater symptom severity and whether this relationship is moderated by age, gender, race, or ethnicity. Aim 1 used EHR-linked data from a confidential 2019 survey of 1688 Kaiser Permanente Washington (KPWA) primary care patients. We compared the Single-Item Screen for Cannabis (SIS-C) used routinely in primary care with results documented in the EHR to a confidential reference standard of DSM-5 CUD administered on the survey. The SIS-C demonstrated strong validity for identifying CUD (area under receiver operating characteristic curves (AUC) 0.89 [95% CI: 0.78-0.96]). A threshold of “less than monthly” cannabis use had the best balance of sensitivity (0.88) and specificity (0.83). Aim 2 used data exclusively from the EHR. Substance Use Symptom Checklists (“Symptom Checklists”) were completed 3/1/2015-3/1/2020 as part of systematic follow-up assessment for CUD by 16,140 KPWA patients reporting daily cannabis use, 4,791 patients reporting other drug use, and 2,373 reporting both. We used item response theory to evaluate the psychometric performance of the Symptom Checklist, finding it unidimensional, discriminative, and performing equally well across demographic subgroups. Aim 3 used EHR and claims data from 13,947 KPWA patients reporting daily cannabis use who completed a Symptom Checklist 3/1/2015-3/1/2021, were continuously enrolled at KPWA, and had not received CUD care in the year prior to completing the Symptom Checklist. Using logistic regression with cluster-robust standard errors, we found that symptom severity, as reported on the Symptom Checklist, was positively associated with subsequent CUD diagnosis, initiation of CUD treatment, and ongoing engagement in CUD treatment although probability of all three care elements was generally low. Gender moderated the association between severity and CUD diagnosis such that women were more likely than men to be diagnosed but less likely than men to initiate treatment at the highest levels of severity. Overall, findings support the validity of brief, practical tools to identify and evaluate the spectrum of cannabis use and use disorder. This work lays a foundation for advancing measurement-based care for CUD in primary care

Strategies to increase implementation of pharmacotherapy for alcohol use disorders: a structured review of care delivery and implementation interventions

Abstract Background Effective medications for treating alcohol use disorders (AUD) are available but underutilized. Multiple barriers to their provision have been identified, and optimal strategies for addressing and overcoming barriers to use of medications for AUD treatment remain elusive. We conducted a structured review of published care delivery and implementation studies evaluating interventions that aimed to increase medication treatment for patients with AUD to identify interventions and component strategies that were most effective. Methods We reviewed literature through May 2018 and used networking to identify intervention studies with AUD medication receipt reported as a primary or secondary outcome. Studies were identified as care delivery studies, characterized by patient-level recruitment and willingness to be randomized to candidate treatment options, and implementation studies, characterized by inclusion of all patients treated at sites involved in the study. Each identified study was independently coded by two investigators for strategies used, guided by a published taxonomy of implementation strategies. All authors reviewed coding discrepancies and revised codes based on consensus. After reaching internal consensus, we solicited feedback from lead investigators on studies to code additional strategies. We reviewed implementation strategies used across studies to assess their relationship with medication receipt, as well as alcohol use outcomes, as available. Results Nine studies were identified: four RCTs of care delivery interventions, four quasi-experimental evaluations of large-scale implementation interventions, and one quasi-experimental evaluation of a targeted single-site implementation intervention. Implementation strategies used were variable across studies; no strategy was universally used. Effects of the interventions on receipt of AUD pharmacotherapy and alcohol use outcomes also varied. Three of four care delivery interventions resulted in increased receipt of AUD medications, but only one of these three improved alcohol use outcomes. One large-scale and one single-site implementation intervention were associated with increased AUD medication receipt, and these studies did not assess alcohol use outcomes. Patterns of implementation strategies did not clearly distinguish studies that successfully increased use of pharmacotherapy versus those that did not. Conclusions Our review did not reveal strategies most effective for implementing AUD medications. Interventions designed to overcome identified barriers may have missed the mark, or differences in the intensity or targets of strategies may matter more than differences in strategies. Further research is needed to understand effective implementation methods and to better understand patient-level perspective, preferences and barriers to receipt of medications

Acceptability of a sitting reduction intervention for older adults with obesity

Abstract Background Older adults spend more time sitting than any other age group, contributing to poor health outcomes. Effective behavioral interventions are needed to encourage less sitting among older adults, specifically those with obesity, but these programs must be acceptable to the target population. We explored participant acceptance of a theory-based and technology-enhanced sitting reduction intervention designed for older adults (I-STAND). Methods The 12-week I-STAND intervention consisted of 6 health coaching contacts, a study workbook, a Jawbone UP band to remind participants to take breaks from sitting, and feedback on sitting behaviors (generated from wearing an activPAL device for 7 days at the beginning and mid-point of the study). Semi-structured interviews were conducted with 22 participants after they completed the intervention. Interview transcripts were iteratively coded by a team, and thematic analysis was used to identify and refine emerging themes. Results Overall, participants were satisfied with the I-STAND intervention, thought the sedentary behavior goals of the intervention were easy to incorporate, and found the technologies to be helpful additions to (but not substitutes for) health coaching. Barriers to standing more included poor health, ingrained sedentary habits, lack of motivation to change sedentary behavior, and social norms that dictate when it is appropriate to sit/stand. Facilitators to standing more included increased awareness of sitting, a sense of accountability, daily activities that involved standing, social support, and changing ways of interacting in the home environment. Participants reported that the intervention improved physical health, increased energy, increased readiness to engage in physical activity, improved mood, and reduced stress. Conclusions The technology-enhanced sedentary behavior reduction intervention was acceptable, easy to incorporate, and had a positive perceived health impact on older adults with obesity. Trial registration The I-STAND study was registered at clinicaltrials.gov (ID: NCT02692560) February 2016

Gender and alcohol use

ObjectivesTo investigate whether gender is associated with three recommended stages of the HIV care continuum and whether gender modifies known associations between level of alcohol use and HIV care among US veterans.DesignRetrospective cohort.MethodsVeterans Aging Cohort Study data were used to identify Veterans Health Administration (VA) patients with HIV and AUDIT-C alcohol screening from 1 February 2008 to 30 September 2014. Modified Poisson regression models estimated the relative risk and predicted prevalences of engagement in HIV care (documented CD4 cells/μl or viral load copies/ml lab values), ART treatment (at least one prescription), and viral suppression (HIV RNA &lt;500 copies/ml) in the year following AUDIT-C (1) for women compared to men, and (2) for each level of alcohol use compared to nondrinking among women and among men. A multiplicative interaction between gender and alcohol use was tested.ResultsAmong 33 224 patients, women (n = 971) were less likely than men (n = 32 253) to receive HIV care (P values &lt;0.001). Respective predicted prevalences for women and men were 71.9% (95% CI 69.1-74.7%) and 77.9% (77.5-78.4%) for engagement, 60.0% (57.0-73.14%) and 73.8% (73.4-74.3%) for ART treatment, and 46.4% (43.3-49.6%) and 55.8% (55.3-56.3%) for viral suppression. Although the interaction between gender and alcohol use was not statistically significant, stratified analyses suggested worse outcomes for women than men at higher levels of alcohol use.ConclusionIn this large national cohort, women were less likely than men to be engaged in HIV medical care, prescribed ART, and virally suppressed. Interventions to improve HIV care for women are needed at all levels of alcohol use

Prevalence of medical cannabis use and associated health conditions documented in electronic health records among primary care patients in Washington State.

Importance: Many people use cannabis for medical reasons despite limited evidence of therapeutic benefit and potential risks. Little is known about medical practitioners' documentation of medical cannabis use or clinical characteristics of patients with documented medical cannabis use. Objectives: To estimate the prevalence of past-year medical cannabis use documented in electronic health records (EHRs) and to describe patients with EHR-documented medical cannabis use, EHR-documented cannabis use without evidence of medical use (other cannabis use), and no EHR-documented cannabis use. Main Outcomes and Measures: Health conditions for which cannabis use has potential benefits or risks were defined based on National Academies of Sciences, Engineering, and Medicine's review. The adjusted prevalence of conditions diagnosed in the prior year were estimated across 3 categories of EHR-documented cannabis use with logistic regression. Results: A total of 185 565 patients (mean [SD] age, 52.0 [18.1] years; 59% female, 73% White, 94% non-Hispanic, and 61% commercially insured) were screened for cannabis use in a primary care visit during the study period. Among these patients, 3551 (2%) had EHR-documented medical cannabis use, 36 599 (20%) had EHR-documented other cannabis use, and 145 415 (78%) had no documented cannabis use. Patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential benefits compared with patients with other cannabis use or no cannabis use. In addition, patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential risks compared with patients with other cannabis use or no cannabis use. Conclusions and Relevance: In this cross-sectional study, primary care patients with documented medical cannabis use had a high prevalence of health conditions for which cannabis use has potential benefits, yet a higher prevalence of conditions with potential risks from cannabis use. These findings suggest that practitioners should be prepared to discuss potential risks and benefits of cannabis use with patients

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

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

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

Abstract 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)

Alcohol Use and Antiretroviral Adherence Among Patients Living with HIV: Is Change in Alcohol Use Associated with Change in Adherence?

Alcohol use increases non-adherence to antiretroviral therapy (ART) among persons living with HIV (PLWH). Dynamic longitudinal associations are understudied. Veterans Aging Cohort Study (VACS) data 2/1/2008-7/31/16 were used to fit linear regression models estimating changes in adherence (% days with ART medication fill) associated with changes in alcohol use based on annual clinically-ascertained AUDIT-C screening scores (range - 12 to + 12, 0 = no change) adjusting for demographics and initial adherence. Among 21,275 PLWH (67,330 observations), most reported no (48%) or low-level (39%) alcohol use initially, with no (55%) or small (39% ≤ 3 points) annual change. Mean initial adherence was 86% (SD 21%), mean annual change was - 3.1% (SD 21%). An inverted V-shaped association was observed: both increases and decreases in AUDIT-C were associated with greater adherence decreases relative to stable scores [p &lt; 0.001, F (4, 21,274)]. PLWH with dynamic alcohol use (potentially indicative of alcohol use disorder) should be considered for adherence interventions