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Contents lists available at ScienceDirect

Drug and Alcohol Dependence

jo ur nal homep ag e: www.elsev ier .com/ locate /drugalcdep

revalence of clinically recognized alcohol and other substance useisorders among VA outpatients with unhealthy alcohol use identifiedy routine alcohol screening�

mily C. Williamsa,d,∗, Anna D. Rubinskya,b,d, Gwen T. Laphama,f, Laura J. Chaveza,d,tacey E. Rittmuellera, Eric J. Hawkinsa,b,e, Joel R. Grossbarda,b, Daniel R. Kivlahana,b,e,atharine A. Bradleya,b,c,d,f

Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, Veteran Affairs (VA) Pugetound Health Care System, Seattle, WA, United StatesCenter of Excellence for Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, United StatesDepartment of Medicine, University of Washington, Seattle, WA, United StatesDepartment of Health Services, University of Washington, Seattle, WA, United StatesDepartment of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United StatesGroup Health Research Institute, Seattle, WA, United States

r t i c l e i n f o

rticle history:eceived 23 July 2013eceived in revised form1 November 2013ccepted 16 November 2013vailable online xxx

eywords:lcohol use disorderslcohol screeningubstance use disorders

a b s t r a c t

Objective: The purpose of routine alcohol screening is to identify patients who may benefit from brief inter-vention, but patients who also have alcohol and other substance use disorders (AUD/SUD) likely requiremore intensive interventions. This study sought to determine the prevalence of clinically documentedAUD/SUD among VA outpatients with unhealthy alcohol use identified by routine screening.Methods: VA patients 18–90 years who screened positive for unhealthy alcohol use (AUDIT-C ≥3 women;≥4 men) and were randomly selected for quality improvement standardized medical record review(6/06–6/10) were included. Gender-stratified prevalences of clinically documented AUD/SUD (diagnosisof AUD, SUD, or alcohol-specific medical conditions, or VA specialty addictions treatment on the dateof or 365 days prior to screening) were estimated and compared across AUDIT-C risk groups, and thenrepeated across groups further stratified by age.Results: Among 63,397 eligible patients with unhealthy alcohol use, 25% (n = 2109) women and 28%(n = 15,199) men had documented AUD/SUD (p < 0.001). The prevalence of AUD/SUD increased withincreasing AUDIT-C risk, ranging from 13% (95% CI 13–14%) to 82% (79–85%) for women and 12% (11–12%)

to 69% (68–71%) for men in the lowest and highest AUDIT-C risk groups, respectively. Patterns were similaracross age groups.Conclusions: One-quarter of all patients with unhealthy alcohol use, and a majority of those with thehighest alcohol screening scores, had clinically recognized AUD/SUD. Healthcare systems implementingevidence-based alcohol-related care should be prepared to offer more intensive interventions and/or

ies fo

effective pharmacotherap

Please cite this article in press as: Williams, E.C., et al., Prevalenceorders among VA outpatients with unhealthy alcohol use identifiehttp://dx.doi.org/10.1016/j.drugalcdep.2013.11.016

� This study was supported by the Veteran’s Affairs (VA) Substance Use Disordersuality Enhancement Research Initiative (SUD QuERI) and the Denver-Seattle Cen-

er of Innovation for Veteran-Centered and Value-Driven Care. Views expressed inhis article are those of the authors and do not necessarily represent the views ofhe Department of Veterans Affairs or the University of Washington. A preliminaryersion of this work was presented at the 2010 Annual Meeting of Academy Health.∗ Corresponding author at: VA Puget Sound Health Care System, 1100 Olive Way,

uite 1400, Seattle, WA 98101, United States. Tel.: +1 206 277 6133;ax: +1 206 764 2935.

E-mail address: emily.williams3@va.gov (E.C. Williams).

376-8716/$ – see front matter Published by Elsevier Ireland Ltd.ttp://dx.doi.org/10.1016/j.drugalcdep.2013.11.016

r these patients.Published by Elsevier Ireland Ltd.

1. Introduction

Unhealthy alcohol use ranges from drinking above recom-mended limits to meeting diagnostic criteria for alcohol usedisorders (Saitz, 2005b). Multiple trials have demonstrated theefficacy of brief interventions for reducing drinking among pri-mary care patients with unhealthy alcohol use (Kaner et al., 2007).While patients with unhealthy alcohol use were identified for tri-als of brief interventions via population-based alcohol screening,

of clinically recognized alcohol and other substance use dis-d by routine alcohol screening. Drug Alcohol Depend. (2013),

most trials subsequently excluded patients with alcohol or othersubstance use disorders (Guth et al., 2008). Therefore, althoughalcohol screening and brief intervention are recommended by theU.S. Preventive Services Task Force (Jonas et al., 2012) and together

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ave been deemed the third highest prevention priority for U.S.dults (Maciosek et al., 2006; Solberg et al., 2008), a recent meta-nalysis concluded that evidence in support of brief interventionsor unhealthy alcohol use may not generalize to those with alco-ol or other substance use disorders (Jonas et al., 2012). As more

ntensive interventions might be required for these patients (Antont al., 2006; Bischof et al., 2008; Brown et al., 2007; Guth et al., 2008;elzer et al., 2008; Kristenson et al., 1983, 2002; Saitz et al., 2008;illenbring and Olson, 1999), it is important to know the poten-

ial need for such services among those who screen positive fornhealthy alcohol use.

Previous research suggests that the prevalence of alcohol andther substance use disorders is highest among men, young adults,nd those with the highest levels of self-reported alcohol consump-ion (Dawson et al., 2005a,b, 2012; Rubinsky et al., 2013, 2010).esearch also suggests that clinicians are less likely to recognizelcohol and other substance use disorders among women com-ared to men (Amodei et al., 1996; Dawson et al., 1992; Gentilellot al., 1999; Keyes et al., 2008, 2010), though the severity of riskelated to alcohol use is generally higher for women than ment similar consumption levels (Hasin et al., 2007; Rubinsky et al.,013; Urbano-Marquez et al., 1995). Although a previous study sug-ested that alcohol and other substance use disorders are commonmong patients with unhealthy alcohol use identified by screeningLapham et al., 2012), the prevalence of alcohol and other substancese disorders among subgroups of patients identified by routinelinical screening is unknown.

While most healthcare systems have not implemented rou-ine screening for unhealthy alcohol use (Williams et al., 2011),he nationwide Veterans Health Administration (VA) implemented

performance measure in 2004 that incentivizes annual alcoholcreening (Bradley et al., 2007b, 2006), and over 90% of VA outpa-ients engaged in routine care are screened annually for unhealthylcohol use. Thus, the VA provides a unique source of data toescribe the sub-populations of screen-positive patients who maye in need of more intensive interventions. The purpose of thistudy was to determine the prevalence of clinically documentedlcohol and other substance use disorders across gender, age, andlcohol use severity among VA outpatients with unhealthy alcoholse identified by routine screening.

. Methods

.1. Data source and study sample

This cross-sectional study used secondary clinical and administrative data from national sample of outpatients randomly selected for standardized record reviewy the VA Office of Analytics and Business Intelligence’s External Peer Review Pro-ram (EPRP). EPRP conducts monthly standardized medical record reviews for eachA medical center to monitor adherence to national performance measures andther recommended care. EPRP oversamples women ages 20 to 69 to monitor adher-nce to gender-specific care. Patients eligible for each month’s EPRP sample includehose who had an outpatient visit in VA 13–24 months before the date of medicalecord review (to establish engagement with VA care); were not included in therevious fiscal year’s EPRP sampling; and had an outpatient visit in the month pre-eding record review. Unique patients from EPRP were identified based on their firstocumented alcohol screen between July, 2006 and June, 2007 and were included

n the present analyses if they screened positive for unhealthy alcohol use (AUDIT-C3 points for women and ≥4 points for men; Bradley et al., 2003; Bush et al., 1998).atients <18 and >90 years old (0.003% of study-eligible patients), as well as thoseith documented cognitive impairment and those enrolled in hospice (0.003% of

PRP sampled-patients; Bradley et al., 2013) were excluded. Demographic and diag-ostic information was obtained from the VA’s National Patient Care Databases.he study, including waivers of informed consent and HIPAA authorization, waspproved by the VA Puget Sound Institutional Review Board.

.2. Measures

Please cite this article in press as: Williams, E.C., et al., Prevalenceorders among VA outpatients with unhealthy alcohol use identifiehttp://dx.doi.org/10.1016/j.drugalcdep.2013.11.016

.2.1. Patient demographic and clinical characteristics. Patient characteristicsncluded age (<25, 25–34, 35–49, 50–64, and ≥65 years), race/ethnicity (Black,ispanic, White, Other, and Unknown), marital status (married vs. not) and insur-nce/disability status (exemption from the mandatory VA co-pay based on lowncome or disability). Clinical characteristics included tobacco use (medical record

PRESSDependence xxx (2013) xxx– xxx

documentation of patient-reported current tobacco use on the date of or 365days prior to alcohol screening), and any mental health diagnosis (administrativedocumentation of International Classification of Diseases, Ninth Revision ClinicalModification codes [ICD-9-CM] for schizophrenia; episodic mood or delusional dis-order; other non-organic psychosis; post-traumatic stress disorder; other anxiety,personality, or depressive disorder; adjustment reaction; physiological malfunctionarising from mental factors; acute reaction to stress; undersocialized conduct dis-order; or disorder of impulse control on the date of or 365 days prior to alcoholscreening).

2.2.2. Primary outcome—any clinically documented alcohol or substance use disor-der. Inpatient and outpatient ICD-9-CM diagnoses and administrative visit codeswere used to derive outcome measures. The primary outcome—any clinically doc-umented alcohol or substance use disorder—was defined as documentation of any ofthe following on the date of or 365 days prior to alcohol screening: (1) alcohol usedisorder (ICD-9-CM diagnosis for abuse or dependence), (2) alcohol-specific medicaldiagnosis (ICD-9-CM diagnosis for intoxication, withdrawal, alcoholic cardiomyopa-thy, alcoholic polyneuropathy, alcoholic gastritis, alcoholic liver disease, alcoholicdementia, or alcohol toxicity), (3) non-alcohol substance use disorder (ICD-9-CM diag-nosis for cannabis, hallucinogen, sedative, opioid, cocaine, or amphetamine abuse ordependence), and (4) documented VA specialty addiction treatment determined fromadministrative codes representing a visit to any VA specialty addictions – clinic.

2.2.3. Unhealthy alcohol use and alcohol use risk groups. Unhealthy alcohol use wasassessed with the 3-item Alcohol Use Disorders Identification Test Consumption(AUDIT-C) questionnaire, which is routinely administered in the VA. The AUDIT-Chas been validated in Veteran male (Bush et al., 1998) and female (Bradley et al.,2003) outpatients, as well as in a general primary care population (Bradley et al.,2007a), and a general U.S. sample (Dawson et al., 2005b). Scores on the AUDIT-Crange from 0 to 12; thresholds of 3 (women) and 4 (men) best balance sensitivityand specificity for detecting unhealthy alcohol use (Bradley et al., 2003, 2007a; Bushet al., 1998). Because higher AUDIT-C scores reflect greater severity of unhealthyalcohol use (Bradley et al., 2004; Rubinsky et al., 2013, 2010), AUDIT-C scores werecategorized to represent groups with increasing risk. Scores of 3–5 (women) or 4–5(men), 6–7, 8–9, and 10–12 points represent mild, moderate, severe, and very severeunhealthy alcohol use, respectively (Au et al., 2007; Kinder et al., 2009; Williamset al., 2012, 2010). Because the VA began incentivizing brief intervention during thestudy period for patients with AUDIT-C scores of 5 or more (Lapham et al., 2012),which may have resulted in greater assessment for and/or documentation of alcoholor substance use disorders in patients with scores of 5 or more, scores for mildunhealthy alcohol use were split into two groups—3–4 (women)/4 (men) and 5.

2.3. Analyses

All analyses were unadjusted in order to describe the true prevalence of clinicallydocumented alcohol or substance use disorders. Initial analyses described patientcharacteristics, the prevalence of the primary outcome (any clinically documentedalcohol or substance use disorder), and the prevalence of each of the componentmeasures that made up the primary outcome, both overall and by gender. Between-gender comparisons in characteristics and outcome measures were conducted usingChi-square tests of independence.

All subsequent analyses used patient-level logistic regression models clusteredon VA medical center to account for similar diagnostic practices by facility usingpopulation-average estimators. We first estimated the unadjusted prevalence and95% confidence interval (CI) of the primary outcome, as well as each of its compo-nents, for each age group stratified by gender. We then estimated the unadjustedprevalence and 95% CI of only the primary outcome across AUDIT-C risk groupsamong subgroups defined first by gender and then by both gender and age. Based onprevious research demonstrating greater prevalence of alcohol use disorders acrossAUDIT-C risk groups for women than men and greater alcohol use disorder sever-ity across AUDIT-C risk groups among younger versus older age groups (Rubinskyet al., 2013), multiplicative interactions between gender and AUDIT-C risk groupsand between age and AUDIT-C risk groups were tested.

Because alcohol dependence represents the most severe unhealthy alcohol use,may be least responsive to brief intervention (Jonas et al., 2012), and can be treatedwith medications without receipt of specialty addictions treatment (Anton et al.,2006), we repeated the above logistic regression analyses to describe the prevalenceof clinically documented alcohol dependence alone. All analyses were completedusing Stata 12 (StataCorp., 2007).

3. Results

Among unique VA outpatients between 18 and 90 years withdocumented alcohol screening whose records were randomly

of clinically recognized alcohol and other substance use dis-d by routine alcohol screening. Drug Alcohol Depend. (2013),

reviewed for quality improvement between July 2006 and June2010 (n = 436,466), 63,397 (15%) screened positive for unhealthyalcohol use and were included. This included 54,913 (15% of362,944) men and 8484 (12% of 73,522) women. Most eligible

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Table 1Demographic and clinical characteristics of the study sample of male and female VA outpatients who screened positive for unhealthy alcohol use between 2006 and 2010(n = 63,397).

Female (n = 8484) Male (n = 54,913) Total (n = 63,397) p-Value comparingwomen and men

n (%) n (%) n (%)

Age <0.00118–25 196 (2) 2082 (4) 2278 (4)25–34 995 (12) 4642 (8) 5637 (9)35–49 3007 (35) 6428 (12) 9435 (15)50–64 3727 (44) 22,694 (41) 26,421 (42)65–90 559 (7) 19,067 (35) 19,626 (31)

Race <0.001Black 560 (7) 2623 (5) 3183 (5)Hispanic 70 (1) 844 (2) 914 (2)White 1725 (21) 12,888 (26) 14,613 (25)Other 25 (0) 179 (0) 204 (0)Unknown 5897 (71) 33,442 (67) 39,339 (68)

Married 2444 (29) 27,312 (50) 29,756 (47) <0.001Exempt from mandatory VA co-payment 6770 (80) 37,717 (69) 44,487 (70) <0.001Tobacco use (past year) 4016 (47) 24,066 (44) 28,082 (44) <0.001Any mental health diagnosis 5169 (61) 23,054 (42) 28,223 (45) <0.001AUDIT-C risk groups among screen positive outpatients <0.001

Screen negative NA NA NA NA NA NAMild unhealthy alcohol use

Score 3–4 (women)/4 (men) 5782 (68) 24,558 (45) 30,340 (48)Score 5a 821 (10) 8575 (16) 9396 (15)

Moderate unhealthy alcohol use (score 6–7) 858 (10) 9192 (17) 10,050 (16)Severe unhealthy alcohol use (score 8–9) 499 (6) 6198 (11) 6697 (11)Very severe unhealthy alcohol use (score 10–12) 524 (6) 6390 (12) 6914 (11)

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A, not applicable.a Cut point at which VA began incentivizing documented brief intervention in Fis

atients were 50 years or older, male, and exempt from paying aandatory VA copayment (Table 1). Tobacco use and mental health

iagnoses were common, and the mild unhealthy alcohol use riskroups (AUDIT-C 3–5 for women and 4–5 for men; Table 1) rep-esented approximately two-thirds of all patients who screenedositive for unhealthy alcohol use. Men were disproportionatelyepresented in the higher AUDIT-C risk groups (Table 1). Womennd men differed significantly from each other on all characteris-ics, except for exemption from mandatory VA copayment (Table 1).pecifically, women were younger on average and less likely to bearried than men, and were more likely than men to be of unknown

ace, use tobacco and have mental health diagnoses (Table 1).Among eligible patients with positive alcohol screening, the

revalence of clinically documented alcohol or other substancese disorders was 27% overall, with men having a slightly higherrevalence than women (28% vs. 25%; p < 0.001; Table 2). Therevalence of clinically documented diagnoses for alcohol andther substance use disorders ranged from 6% to 32% across age

Please cite this article in press as: Williams, E.C., et al., Prevalenceorders among VA outpatients with unhealthy alcohol use identifiehttp://dx.doi.org/10.1016/j.drugalcdep.2013.11.016

roups for women and from 11% to 43% across age groups for menTable 3). The highest prevalence for both women and men wasbserved in the 35–49 year old age group. About 1 in 10 women

able 2ender-specific prevalence of clinically documented alcohol and other substance use diso

Female (n = 8484) Male

n (%) n

Alcohol use disorder 1881 (22) 14,170Non-alcohol substance use disorder 707 (8) 4126Alcohol-specific medical diagnosis 331 (4) 2481VA specialty addictions treatment 910 (11) 5441

Any clinically documented alcohol orother substance use disordera

2109 (25) 15,199

a Primary study outcome: documentation of any alcohol use disorder, any alcohol-specA specialty addictions treatment.

ar 2008.

and men had documented attendance at VA specialty addictionstreatment. Though 8% of both women and men had documentednon-alcohol substance use disorders, most documented diagnoseswere for alcohol use disorders (Table 2), and this was true for bothgenders and in all age groups (Table 3).

The prevalence of clinically documented alcohol and other sub-stance use disorders increased for both genders across increasingAUDIT-C risk groups in the sample (Table 4). Gender moderatedthe association between AUDIT-C risk groups and clinically docu-mented alcohol or other substance use disorders such that womenhad a significantly greater proportional increase in documenteddisorders with increasing AUDIT-C risk groups compared to men(p-value for interaction <0.001). Specifically, the prevalence of clini-cally documented alcohol and other substance use disorders rangedfrom 13% (95% CI 13–14%) to 82% (79–85%) for women and from 12%(11–12%) to 69% (68–71%) for men in the lowest and highest riskgroups, respectively (Table 4). A significant interaction was iden-tified between age and AUDIT-C risk groups (p < 0.001). However,

of clinically recognized alcohol and other substance use dis-d by routine alcohol screening. Drug Alcohol Depend. (2013),

patterns were relatively consistent with the prevalence of clinicallydocumented alcohol and other substance use disorders increas-ing across AUDIT-C risk groups in all age groups despite higher

rders among VA outpatients who screened positive for unhealthy alcohol use.

(n = 54,913) Total (n = 63,397) p-Value comparingwomen and men

(%) n (%)

(26) 16,051 (25) <0.001 (8) 4833 (8) 0.008 (5) 2812 (4) 0.010 (10) 6351 (10) 0.020

(28) 17,308 (27) <0.001

ific medical diagnosis, any non-alcohol substance use disorder, or any documented

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Table 3Gender-specific prevalence of clinically documented alcohol and other substanceuse disorders among VA outpatients who screened positive for unhealthy alcoholuse between 2006 and 2008: stratified by age groups.

Female (n = 8484) Male (n = 54,913)

% (95% CI) % (95% CI)

Alcohol use disorder18–25 14 (9–19) 20 (18–21)25–34 19 (17–22) 24 (23–25)35–49 29 (27–30) 40 (39–41)50–64 20 (19–22) 36 (35–36)65–90 6 (4–7) 10 (10–11)

Non-alcohol substance use disorder18–25 6 (2–9) 5 (4–6)25–34 8 (6–9) 8 (7–8)35–49 12 (11–13) 19 (18–20)50–64 7 (6–8) 10 (10–11)65–90 0 1 (1–1)

Alcohol-specific medical diagnosis18–25 1 (0–2) 1 (0–1)25–34 2 (1–3) 2 (1–2)35–49 5 (4–6) 9 (8–9)50–64 4 (3–5) 7 (7–7)65–90 1 (0–2) 1 (1–2)

VA specialty addictions treatment18–25 7 (3–10) 6 (5–7)25–34 9 (8–11) 9 (8–10)35–49 15 (14–17) 23 (22–24)50–64 9 (8–10) 14 (13–14)65–90 2 (1–3) 2 (1–2)

Any clinically documented alcohol or other substance use disordera

18–25 17 (12–23) 21 (19–23)25–34 23 (20–25) 26 (25–28)35–49 32 (30–33) 43 (42–45)50–64 23 (22–24) 38 (38–39)65–90 6 (4–8) 11 (11–11)

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a Primary study outcome: documentation of any alcohol use disorder, anylcohol-specific medical diagnosis, any non-alcohol substance use disorder, or anyocumented VA specialty addictions treatment.

revalences of disorders observed in the middle three age groupsFig. 1).

The prevalence of alcohol dependence alone was 17%, withrevalences of 15% for women and 18% for men (p < 0.001). Genderoderated the association between AUDIT-C risk groups and clini-

ally documented alcohol dependence (p < 0.001) such that womenad a significantly greater proportional increase in documentedependence with increasing AUDIT-C risk groups compared to

Please cite this article in press as: Williams, E.C., et al., Prevalenceorders among VA outpatients with unhealthy alcohol use identifiehttp://dx.doi.org/10.1016/j.drugalcdep.2013.11.016

en. The prevalence of clinically documented alcohol dependenceanged from 6% (6–7%) to 69% (65–73%) for women and from 7%6–7%) to 52% (51–54%) for men in the lowest and highest AUDIT-Cisk groups, respectively (Table 5). As in the findings for the primary

able 4ender-specific prevalence of any clinically documented alcohol or other substance useetween 2006 and 2010: stratified by AUDIT-C risk group.

Female (n = 8484)

Any clinically documented alcohol

% diagnosed with AUD/SUD (95%

AUDIT-C risk group

Mild unhealthy alcohol useScore 3–4 (women)/4 (men) 13 (13–Score 5 (cut point at which VA incentivizes BI)a 30 (27–

Moderate unhealthy alcohol use (score 6–7) 43 (40–Severe unhealthy alcohol use (score 8–9) 57 (53–Very severe unhealthy alcohol use (score 10–12) 82 (79–

a Cut point at which VA began incentivizing documented brief intervention in Fiscal Ye

PRESSDependence xxx (2013) xxx– xxx

outcome, there was a significant multiplicative interaction betweenage and AUDIT-C risk groups (p < 0.001), but patterns across AUDIT-C risk groups were fairly consistent across age groups (Fig. 2).

To understand whether having received VA specialty addictionscare helped explain observed gender differences in documenteddisorders across AUDIT-C risk groups, we conducted post hoc sec-ondary analyses estimating, for each gender and each AUDIT-Cgroup, the unadjusted prevalence and 95% CI of any documenteddiagnoses for alcohol use disorders, alcohol-specific medical con-ditions, and non-alcohol substance use disorders among patientswith and without documented VA specialty addictions treatment.Among the 6351 (10%) patients with unhealthy alcohol use witha visit to VA specialty addictions treatment in the past year, theprevalence of diagnoses for an alcohol or substance use disorder oralcohol-specific medical condition ranged from 82 (77–88%) to 99%(98–100%) for women and from 88% (85–91%) to 98% (98–99%) formen across AUDIT-C risk groups (Fig. 3). Among the 57,046 (90%) ofpatients with no documented visit to VA specialty addictions treat-ment, the prevalence of these diagnoses ranged from 9% (8–10%) to64% (58–70%) for women and from 9% (8–9%) to 55% (52–57%) formen across AUDIT-C risk groups (Fig. 3).

4. Discussion

This study found that, among patients with unhealthy alco-hol use identified by routine clinical alcohol screening, more thanone-quarter of all patients had clinically recognized alcohol orother substance use disorders, including 25% of women and 28%of men. The prevalence was even higher for patients between theages of 35 and 49, with approximately one-third of women andover 40% of men having clinically recognized disorders in this agegroup. Moreover, irrespective of age, documented disorders weremore common as patients screened positive for increasingly severeunhealthy alcohol use, with ranges from 13% to 82% and 12% to69% for women and men, respectively. For both genders and acrossall age groups, the vast majority of documented diagnoses amongpatients with unhealthy alcohol use were for alcohol use disorderswith more than one-sixth of patients having documented alcoholdependence.

These findings suggest that, in the context of routine screeningfor unhealthy alcohol use, a substantial portion of patients identi-fied by screening will have recognized alcohol or other substanceuse disorders. Although the purpose of routine alcohol screeningis to identify patients who may benefit from brief intervention(Jonas et al., 2012; Solberg et al., 2008), screen-positive patients

of clinically recognized alcohol and other substance use dis-d by routine alcohol screening. Drug Alcohol Depend. (2013),

with alcohol and other substance use disorders will likely requiremore intensive interventions (McKay, 2005; McLellan et al.,2000). While an offer of referral to specialty addictions treat-ment is recommended (National Institute on Alcohol Abuse and

disorder among VA outpatients who screened positive for unhealthy alcohol use

Male (n = 54,913) p-Value for interaction betweengender and AUDIT-C risk group

or other substance use disorder

CI) % diagnosed with AUD/SUD (95% CI)

<0.001

14) 12 (11–12)33) 25 (24–26)46) 32 (31–33)62) 44 (42–45)85) 69 (68–71)

ar 2008.

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0

20

40

60

80

100

3-4/4 5 6- 7 8- 9 10-12 3-4/4 5 6- 7 8- 9 10-12 3-4/4 5 6- 7 8- 9 10-12 3-4/4 5 6- 7 8-9 10-12 3-4/4 5 6- 7 8- 9 10-12

Female %Male %

Prev

alen

ce %

AUDIT-C Group

18-25 years

AUDIT-C Grou p

25-34 years

AUDIT-C Gr oup

35-49 years

AUDIT-C Grou p

50-64 years

AUDIT-C Grou p

65-90 years

Fig. 1. Gender-specific prevalence of clinically documented alcohol or other substance use disorders among VA outpatients who screened positive for unhealthy alcohol use:stratified by AUDIT-C risk and age groups (p-value for age × AUDIT-C group interaction < 0.001).

0

20

40

60

80

100

3-4/4 5 6- 7 8- 9 10-1 2 3- 4/4 5 6- 7 8- 9 10-12 3-4/ 4 5 6-7 8-9 10-12 3-4/4 5 6- 7 8- 9 10-12 3-4/4 5 6- 7 8- 9 10-12

Female %Male %

Prev

alen

ce %

AUDI T-C Group 18-25 year s

AUDIT-C Grou p

25-34 years AUDI T-C Group

35-49 years

AUDIT- C Gr oup

50-64 years AUDIT-C Gr oup

65-90 year s

F ong

a

Ammectc

TGs

ig. 2. Gender-specific prevalence of clinically documented alcohol dependence amnd AUDIT-C risk groups (p-value for age × AUDIT-C group interaction < 0.001).

lcoholism, 2007; VA Office of Quality and Performance, 2009),any patients with alcohol or other substance use disordersay not be interested in specialty addictions treatment (Cohen

t al., 2007). Moreover, treatment of these chronic and relapsing

Please cite this article in press as: Williams, E.C., et al., Prevalenceorders among VA outpatients with unhealthy alcohol use identifiehttp://dx.doi.org/10.1016/j.drugalcdep.2013.11.016

onditions (McLellan et al., 2000) may require models of carehat go beyond the existing acute treatment models typical ofonventional specialty addictions treatment (McKay, 2005; Saitz

able 5ender-specific prevalence of clinically documented alcohol dependence among VA outptratified by AUDIT-C risk group.

Female (n = 8, 484)

Clinically documented alcohol d

% diagnosed withdependence

(95% C

AUDIT-C risk group

Mild unhealthy alcohol useScore 3–4 (women)/4 (men) 6 (6–7)

Score 5 (cut point at which VA incentivizes BI)a 17 (15–20Moderate unhealthy alcohol use (score 6–7) 28 (25–31Severe unhealthy alcohol use (score 8–9) 38 (34–43Very severe unhealthy alcohol use (score 10–12) 69 (65–73

a Cut point at which VA began incentivizing documented brief intervention in Fiscal Ye

VA outpatients who screened positive for unhealthy alcohol use: stratified by age

et al., 2008). Primary care may need to take a more active role inthe management of alcohol and other substance use disorders bydeveloping and implementing more integrated approaches thataddress the medical and mental health needs of patients (McKay,

of clinically recognized alcohol and other substance use dis-d by routine alcohol screening. Drug Alcohol Depend. (2013),

2005; McLellan et al., 2000; Saitz et al., 2008).Although primary-care-based brief interventions for unhealthy

alcohol use do not have clear efficacy for patients with alcohol

atients who screened positive for unhealthy alcohol use between 2006 and 2010:

Male (n = 54,913) p-Value for interaction betweengender and AUDIT-C risk group

ependence

I) % diagnosed withdependence

(95% CI)

<0.001

7 (6–7)) 14 (13–15)) 20 (19–20)) 28 (27–29)) 52 (51–54)

ar 2008.

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se disorders (Guth et al., 2008; Jonas et al., 2012; Moyer et al.,002), repeated interventions (Brown et al., 2007; Willenbringnd Olson, 1999) and several medications (Anton et al., 2006;ational Institute on Alcohol Abuse and Alcoholism, 2007) have

hown promise for managing patients with alcohol use disordersn general medical settings (Lee et al., 2012; Oslin et al., 2013).onetheless, it is unknown how best to deliver repeated interven-

ions in primary care (Bradley and Williams, 2010), and studiesuggest very low uptake of pharmacotherapy for patients with alco-ol use disorders (Mark et al., 2009), including less than 5% ofatients with alcohol dependence in the VA (Harris et al., 2010,012; Iheanacho et al., 2013). While chronic care managementas been recommended for outpatient management of alcohol useisorders (Saitz, 2005a; Saitz et al., 2008), a recent trial amongatients with alcohol and other substance use disorders found noenefit of team-based chronic care management compared to refer-al to primary care for increasing abstinence from heavy drinkingSaitz et al., 2013). However, that trial had several promising find-ngs, including substantial improvements in abstinence among allarticipants, the majority of whom were recruited from residen-ial detoxification, and increased use of addictions treatment andharmacotherapy (secondary trial outcomes) among participantsandomized to team-based chronic care management (Saitz et al.,013). Further research is needed to evaluate new models of care forlcohol use disorders (O’Connor, 2013), and to identify and addressarriers to pharmacotherapy treatment in outpatient settings.

While the majority of diagnoses identified in this study wereor alcohol use disorders, the prevalence of non-alcohol sub-tance use disorders was 8% among patients with positive alcoholcreening. The efficacy of brief alcohol interventions for influenc-ng other substance use outcomes has not been tested, and it isurrently unknown whether brief interventions focused specifi-ally on drug use among patients whose drug use is identifiedy screening are effective (Saitz et al., 2010). However, therere promising approaches to outpatient management of opi-id use disorders (Alford et al., 2011, 2007a,b; Walley et al.,008) and extensive evidence of effectiveness of outpatient spe-ialty care for substance use disorders (Glasner-Edwards andawson, 2010). Our findings suggest that a substantial propor-ion of patients with high alcohol screening scores may also have

Please cite this article in press as: Williams, E.C., et al., Prevalenceorders among VA outpatients with unhealthy alcohol use identifiehttp://dx.doi.org/10.1016/j.drugalcdep.2013.11.016

on-alcohol substance use disorders, and research is needed tonderstand how best to meet the needs of patients with bothnhealthy alcohol use and substance use disorders (O’Connor,013).

other substance use disorders among VA outpatients who screened positive fortion treatment.

While the overall prevalence of alcohol and other substance usedisorders was slightly higher among men than women, womenhad higher documented prevalences in every AUDIT-C risk groupthan men and greater proportional increases at higher risk groups.These findings may reflect increased susceptibility of women toadverse consequences of drinking at any given level of consumption(Nolen-Hoeksema, 2004). However, post hoc secondary analysessuggested that differences in recognized disorders across genderand AUDIT-C risk groups were observed primarily among patientswithout documented attendance at VA specialty addictions care.Given that results from confidential diagnostic interviews foundmen and women had similar proportions of alcohol use disordersat each AUDIT-C score (Rubinsky et al., 2013), findings from thepresent study suggest that, among patients who are not alreadyengaged in specialty addictions care, women are more likely thanmen to have alcohol and other substance use disorders recognizedby clinicians at a given AUDIT-C risk group. These findings are incontrast to previous studies, which have found that women areless likely than men to have alcohol and other substance use disor-ders recognized by clinicians (Burman et al., 2004; Dawson et al.,1992; Volk et al., 1996), and that women may be reluctant to discusstheir alcohol use with providers (Coulehan et al., 1987; Seppa andSillanaukee, 1994). Further research is needed to understand gen-der differences in recognized disorders, especially among patientswho are not engaged in specialty addictions care.

Findings from this study also suggest the possibility that alco-hol and other substance use disorders are being underdiagnosedclinically among some Veteran subpopulations. Interview-basedstudies in the U.S. general population (Dawson et al., 2005a, 2012;Rubinsky et al., 2013), and in a primary care sample in Texas(Rubinsky et al., 2010), have described the prevalence of alcoholuse disorders across some but not all subgroups assessed in thepresent study. These studies found that alcohol use disorders aremost common among men, young adults, those with co-morbidmental health diagnoses, and those with the most severe unhealthyalcohol use (Dawson et al., 2012; Rubinsky et al., 2013, 2010). Sim-ilarly, the present study found that alcohol or other substance usedisorders were most often recognized among those with the mostsevere unhealthy alcohol use (Rubinsky et al., 2013, 2010). How-ever, recognized alcohol and other substance use disorders were

of clinically recognized alcohol and other substance use dis-d by routine alcohol screening. Drug Alcohol Depend. (2013),

most common among those in the middle age groups, and genderdifferences in the overall prevalence were smaller than would beexpected based on interview-based studies. While patterns of alco-hol and other substance use disorders in Veteran outpatients may

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iffer from those in the general population or other primary careamples, further research is needed to assess whether these disor-ers are under-identified clinically in men and among patients inounger age groups.

This study has several limitations. First, we relied on secondarylinical and administrative data to identify the sample populationthose with positive screens for unhealthy alcohol use identified),nstead of directly screening patients. Despite use of a validatedcreening questionnaire, clinical alcohol screening in VA misses aubstantial proportion of patients who screen positive on mailedurveys (Bradley et al., 2011; Hawkins et al., 2007). Underestimatesf the prevalence of unhealthy alcohol use among VA outpatientsould result in overestimates of clinically recognized disorders.econd, results may not be generalizable to other patient popu-ations with lower prevalences of substance use (National Surveyn Drug Use and Health, 2005) and to other healthcare settingshat have not implemented routine alcohol screening, as selectivecreening would likely preferentially screen patients with alcoholse disorders (Burman et al., 2004; Volk et al., 1996). Addition-lly, the sample included VA outpatients whose medical recordsere reviewed for quality improvement, which includes patientsho are routine users of VA and oversamples women, and mayot be representative of VA outpatients overall. Moreover, as aesult of oversampling of women between the ages of 20 and 69,he sample of women included in this study may reflect moref the recently returned veteran population – younger veteransho are more likely to screen positive for unhealthy alcohol use

Hawkins et al., 2010). Therefore, it is possible that the prevalencef unhealthy alcohol use identified among women is an over-stimate. Finally, there were small numbers of women in someubgroups in this study, resulting in relatively large confidencentervals.

Despite these limitations, this study utilized a unique source ofata from a healthcare system in which routine population-basedcreening has been implemented and found that more than oneuarter of VA outpatients with unhealthy alcohol use identified bycreening had clinically recognized alcohol or other substance useisorders, including a majority of men and women with the highestlcohol screening scores. While routine brief intervention shoulde offered to all outpatients who screen positive for unhealthylcohol use (Jonas et al., 2012), health care systems implemen-ing evidence-based care for unhealthy alcohol use may need toncrease access to more intensive interventions and/or effectiveharmacotherapies for patients with unhealthy alcohol use, espe-ially among some subgroups, regardless of treatment seeking oretting (National Institute on Alcohol Abuse and Alcoholism, 2007;A Office of Quality and Performance, 2009).

ole of funding source

Data for this study were provided by the VA Office of Analyt-cs and Business Intelligence. This work was supported by the VAubstance Use Disorders Quality Enhancement Research Initiativend VA Puget Sound HSR&D. Dr. Rubinsky was also supported byn AHRQ/NRSA T-32 training grant at the University of Washing-on. Dr. Williams is supported by a Career Development Awardrom VA Health Services Research & Development (CDA 12-276).r. Williams is also an investigator with the Implementationesearch Institute (IRI) at the George Warren Brown School ofocial Work at Washington University in St. Louis. IRI is supported

Please cite this article in press as: Williams, E.C., et al., Prevalenceorders among VA outpatients with unhealthy alcohol use identifiehttp://dx.doi.org/10.1016/j.drugalcdep.2013.11.016

hrough an award from the National Institute of Mental Health (R25H080916-01A2) and the Department of Veterans Affairs, Health

ervices Research & Development Service, Quality Enhancementesearch Initiative (QUERI).

PRESSDependence xxx (2013) xxx– xxx 7

A final version of the manuscript was approved for submissionby VA Research & Development and by VA Office of Analytics andBusiness Intelligence. However, supporters had no role in studydesign, data analysis or interpretation, report writing, or the deci-sion to submit the paper for publication.

Contributors

All authors contributed to study design, protocol development,and data interpretation. Drs. Williams and Rubinsky took thelead on data analysis and manuscript drafting; Dr. Lapham andMs. Chavez contributed to data analysis and initial manuscriptdrafting; Ms. Rittmueller managed literature searches, supportedmanuscript preparation and submission and led data presentationefforts; Drs. Hawkins, Grossbard, and Kivlahan participated in iter-ative review of data analysis and presentation; Dr. Bradley servedas principal investigator of the study and guided all stages of studydesign, analysis, interpretation and presentation. All authors con-tributed to and have approved the final manuscript.

Conflict of interest

Dr. Bradley owns stocks in four pharmaceutical companies. Noauthor has any actual or potential conflict of interest includingfinancial, personal or other relationships with other people or orga-nizations within three years of beginning the work that couldinappropriately influence, or be perceived to influence, their work.

Acknowledgments

No further acknowledgments are listed beyond those listed inthe article and above, which acknowledge the provision of datafrom VA’s Office of Analytics and Business Intelligence and thesupport from the funding sources listed above.

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