Back Pain Consortium (BACPAC): Protocol and Pilot Study Results for a Randomized Comparative-Effectiveness Trial of Antidepressants, Fear Avoidance Rehabilitation, or the Combination for Chronic Low Back Pain and Comorbid High Negative Affect.

OBJECTIVE: Patients with chronic low back pain (CLBP) and comorbid depression or anxiety disorders are highly prevalent. Negative affect (NA) refers to a combination of negative thoughts, emotions, and behaviors. Patients with CLBP with high NA have greater pain, worse treatment outcomes, and greater prescription opioid misuse. We present the protocol for SYNNAPTIC (SYNergizing Negative Affect & Pain Treatment In Chronic pain). DESIGN: A randomized comparative-effectiveness study of antidepressants, fear-avoidance rehabilitation, or their combination in 300 patients with CLBP with high NA. In the antidepressant- or rehabilitation-only arms, SYNNAPTIC includes an adaptive design of re-randomization after 4 months for nonresponders. SETTING: A multisite trial conducted in routine pain clinical treatment settings: pain clinics and physical and occupational therapy treatment centers. METHODS: Inclusion criteria include CLBP with elevated depression and anxiety symptoms. Antidepressant and rehabilitation treatments follow validated and effective protocols for musculoskeletal pain in patients with high NA. Power and sample size are based on superior outcomes of combination therapy with these same treatments in a 71-subject 4-arm pilot randomized controlled trial. CONCLUSIONS: SYNNAPTIC addresses the lack of evidence-based protocols for the treatment of the vulnerable subgroup of patients with CLBP and high NA. We hypothesize that combination therapy of antidepressants plus fear-avoidance rehabilitation will be more effective than each treatment alone. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04747314.

Implementing harm reduction kits in an office-based addiction treatment program.

BACKGROUND: The rising rates of drug use-related complications call for a paradigm shift in the care for people who use drugs. While addiction treatment and harm reduction have historically been siloed in the US, co-location of these services in office-based addiction treatment (OBAT) settings offers a more realistic and patient-centered approach. We describe a quality improvement program on integrating harm reduction kits into an urban OBAT clinic. METHODS: After engaging appropriate stakeholders and delivering clinician and staff trainings on safer use best practices, we developed a clinical workflow for universal offering and distribution of pre-packaged kits coupled with patient-facing educational handouts. We assessed: (1) kit uptake with kit number and types distributed; and (2) implementation outcomes of feasibility, acceptability, appropriateness, and patient perceptions. RESULTS: One-month post-implementation, 28% (40/141) of completed in-person visits had at least one kit request, and a total of 121 kits were distributed. Staff and clinicians found the program to be highly feasible, acceptable, and appropriate, and patient perceptions were positive. CONCLUSIONS: Incorporating kits in OBAT settings is an important step toward increasing patient access and utilization of life-saving services. Our program uncovered a significant unmet need among our patients, suggesting that kit integration within addiction treatment can improve the standard of care for people who use drugs.

Twelve-Month Retention in Opioid Agonist Treatment for Opioid Use Disorder Among Patients With and Without HIV.

Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.

Using Intervention Mapping to Develop a Novel Pain Self-Management Intervention for People with Cirrhosis.

BACKGROUND: Chronic pain is common among patients with cirrhosis and is challenging to treat. While promising, pain self-management (PSM) interventions have not been tailored to this population's needs. AIMS: To design a PSM intervention for patients with cirrhosis. METHODS: Semi-structured interviews with 17 patients with cirrhosis, 12 hepatologists, and 6 administrators from two medical centers were conducted to inform a rigorous, structured intervention mapping (IM) process. Qualitative content analysis was guided by social cognitive theory (SCT) and the Consolidated Framework for Implementation Research (CFIR) and incorporated into intervention development. A planning group met regularly throughout the intervention, to reach consensus about how to use data and theory to develop the intervention through IM. RESULTS: Participants described barriers to PSM behaviors, including the absence of simple, evidence-based interventions for pain for patients with cirrhosis, inadequate provider knowledge, time, and training, and lack of champions, funding, and communication. Patients described high motivation to treat pain using behavioral methods including meditation, prayer, and exercise. The intervention was designed to address barriers to PSM behaviors for patients with cirrhosis, using behavior change methods that address knowledge, self-efficacy, and outcome expectations. The LEAP (Liver Education About Pain) intervention is a 12-week, modular intervention delivered by phone via individual and group sessions with a health coach. CONCLUSIONS: People with cirrhosis, hepatologists, and administrators informed this theory-driven, tailored PSM intervention, which was designed to be implementable in the real world.

Impact of Alcohol Use Disorder Treatment on Clinical Outcomes Among Patients With Cirrhosis.

BACKGROUND AND AIMS: Despite the significant medical and economic consequences of coexisting alcohol use disorder (AUD) in patients with cirrhosis, little is known about AUD treatment patterns and their impact on clinical outcomes in this population. We aimed to characterize the use of and outcomes associated with AUD treatment in patients with cirrhosis. APPROACH AND RESULTS: This retrospective cohort study included Veterans with cirrhosis who received Veterans Health Administration care and had an index diagnosis of AUD between 2011 and 2015. We assessed the baseline factors associated with AUD treatment (pharmacotherapy or behavioral therapy) and clinical outcomes for 180 days following the first AUD diagnosis code within the study time frame. Among 93,612 Veterans with cirrhosis, we identified 35,682 with AUD, after excluding 2,671 who had prior diagnoses of AUD and recent treatment. Over 180 days following the index diagnosis of AUD, 5,088 (14%) received AUD treatment, including 4,461 (12%) who received behavioral therapy alone, 159 (0.4%) who received pharmacotherapy alone, and 468 (1%) who received both behavioral therapy and pharmacotherapy. In adjusted analyses, behavioral and/or pharmacotherapy-based AUD treatment was associated with a significant reduction in incident hepatic decompensation (6.5% vs. 11.6%, adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI], 0.52, 0.76), a nonsignificant decrease in short-term all-cause mortality (2.6% vs. 3.9%, AOR, 0.79; 95% CI, 0.57, 1.08), and a significant decrease in long-term all-cause mortality (51% vs. 58%, AOR, 0.87; 95% CI, 0.80, 0.96). CONCLUSIONS: Most Veterans with cirrhosis and coexisting AUD did not receive behavioral therapy or pharmacotherapy treatment for AUD over a 6-month follow-up. The reductions in hepatic decompensation and mortality suggest that future studies should focus on delivering evidence-based AUD treatments to patients with coexisting AUD and cirrhosis.

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 < 0.001, F (4, 21,274)]. PLWH with dynamic alcohol use (potentially indicative of alcohol use disorder) should be considered for adherence interventions.

RESUMEN: El consumo de alcohol aumenta el no-cumplimiento a la terapia antirretroviral (TARV) entre las personas que viven con VIH. No se han estudiado lo suficiente las dinámicas asociaciones longitudinales. Los datos del Estudio de la Envejecimiento de Cohorte de Veteranos (EECV) (1/2/2008­31/7/2016) fueron usados para encajar modelos de regresión lineal estimando los cambios en cumplimiento (% de días con medicaciones TARV surtidas) asociados con los cambios en el consumo de alcohol basado en los resultados anuales de las evaluaciones AUDIT-C, determinadas clínicamente, (una gama de -12 a + 12, 0 = cero cambio) adaptándose a las estadísticas demográficas y cumplimiento inicial. Entre 21,275 personas que viven con VIH (67,330 observaciones), la mayoría reportó ningún (48%) o bajos niveles del (39%) consumo de alcohol inicialmente, con ningún (55%) o muy pequeño (39% ≤ 3 puntos) cambio anual. la media inicial de cumplimiento fue 86% (DE 21%). La media de cambio anual fue -3.1% (DE 21%). Se observó una asociación de forma V invertida: tanto los aumentos como las disminuciones en AUDIT-C fueron asociados con mayor disminuciones de cumplimiento en comparación con resultados estables (p < 0.001, F (4, 21,274)). Personas que viven con VIH con el consumo dinámico de alcohol (potencialmente indicativo de un trastorno por consumo de alcohol) deben ser considerados por intervenciones de cumplimiento.

Characteristics of Opioid Prescriptions to Veterans With Cirrhosis.

BACKGROUND & AIMS: Despite increased risks for adverse effects in patients with cirrhosis, little is known about opioid prescriptions for this population. We aimed to assess time trends in opioid prescribing and factors associated with receiving opioids among patients with cirrhosis. METHODS: Among Veterans with cirrhosis, identified using national Veterans Health Administration data (2005-2014), we assessed characteristics of patients and their prescriptions for opioids. We calculated the annual proportion of patients receiving any opioid prescription. Among opioid recipients, we assessed prescriptions that were long-term (>90 days' supply), for high doses (>100 MME/day), or involved combinations of opioids and acetaminophen or benzodiazepine. We evaluated patient characteristics independently associated with long-term and any opioid prescriptions using mixed-effects regression models. RESULTS: Among 127,239 Veterans with cirrhosis, 97,974 (77.0%) received a prescription for an opioid. Annual opioid prescriptions increased from 36% in 2005 to 47% in 2014 (P < .01). Among recipients of opioids, the proportions of those receiving long-term prescriptions increased from 47% in 2005 to 54% in 2014 (P < .01), and19%-21% received prescriptions for high-dose opioids. Prescriptions for combinations of opioids and acetaminophen decreased from 68% in 2005 to 50% in 2014 (P < .01) and for combinations of opioids and benzodiazepines decreased from 24% to 19% over this time (P < .01). Greater probability of long-term opioid prescriptions was independently associated with younger age, female sex, white race, hepatitis C, prior hepatic decompensation, hepatocellular carcinoma, mental health disorders, nicotine use disorders, medical comorbidities, surgery, and pain-related conditions. CONCLUSION: Among Veterans with cirrhosis, 36%-47% were prescribed opioids in each year. Mental health disorders and hepatic decompensation were independently associated with long-term opioid prescriptions.

Association of Cannabis, Stimulant, and Alcohol use with Mortality Prognosis Among HIV-Infected Men.

Questionnaires over a 9-year study period (2002-2010) were used to characterize cannabis, stimulant, and alcohol use among 3099 HIV-infected men participating in the Veterans Aging Cohort Study (VACS) to determine whether use of these substances is associated with changes in the VACS Index, a validated prognostic indicator for all-cause mortality. At baseline, 18% of participants reported no substance use in the past year, 24% lower risk alcohol use only, 18% unhealthy alcohol use only, 15% cannabis use (with or without alcohol), and 24% stimulant use (with or without alcohol or cannabis). In adjusted longitudinal analyses, cannabis use [ß = -0.97 (95% CI -1.93, 0.00), p = 0.048] was not associated with mortality risk, while stimulant use [1.08 (0.16, 2.00), p = 0.021] was associated with an increased mortality risk, compared to lower risk alcohol use. Our findings show no evidence of a negative effect of cannabis use on mortality risk, while stimulant use was associated with increased mortality risk among HIV-infected men. Interventions to reduce stimulant use in this patient population may reduce mortality.

Correction to: Association of Cannabis, Stimulant, and Alcohol use with Mortality Prognosis Among HIV-Infected Men.

In the original publication of the article, the given and family name of the third author was not correct. The name has been corrected with this erratum.

Education for the mind and the heart? Changing residents' attitudes about addressing unhealthy alcohol use.

BACKGROUND: Screening and brief intervention counseling for unhealthy alcohol use are among the top 10 recommended clinical preventive services for US adults. Although federally funded training programs in alcohol screening, brief intervention, and referral to treatment (SBIRT) have focused on increasing physicians' professional readiness to address drinking with their patients, programs typically focus on knowledge and skill acquisition, with less attention to attitudinal change. The purpose of this study was to assess the impact of a multicomponent SBIRT training program on changes in internal medical residents' professional readiness for working with patients with unhealthy alcohol use. METHODS: Between 2011 and 2013, first-year internal medicine residents (n = 80) at a large academic medical center participated in a 16-hour SBIRT training program, consisting of two 3-hour didactic sessions, online modules, and a half-day clinical experience, during the Ambulatory Care month of the residency training year. Residents completed a modified Alcohol and Problems Perceptions Questionnaire (AAPPQ) at the beginning and end of the residency year to assess changes in professional readiness to work with adults with unhealthy alcohol use across 6 domains: Role Adequacy, Role Legitimacy, Role Support, Motivation, Task-Specific Self-esteem, and Satisfaction. Wilcoxon signed-rank tests were used to evaluate changes in the 6 AAPPQ subscale scores over time. RESULTS: Residents reported significant increases in Role Adequacy (alcohol-related knowledge/skills; pre: 34 and post: 39.5; P < .0001) and Role Support (professional support; pre: 16 and post: 18; P = .005) scores. No significant differences in the remaining AAPPQ subscales were detected. CONCLUSIONS: Residents in the SBIRT training program indicated improvements in knowledge, skills, and professional role support but not in motivation, task-specific self-esteem, or satisfaction for working with patients with unhealthy alcohol use. Explicit curricular attention to these domains may be required to facilitate SBIRT skills application and sustained practice change.

The Surgeon General's Facing Addiction report: An historic document for health care.

The publication of Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health presents an historic moment not only for the field of addiction medicine, but also for the United States as a nation. The Board of Directors of the Association for Medical Education and Research in Substance Abuse (AMERSA), on behalf of our organization, would like to express our appreciation of the efforts of Dr. Vivek Murthy and the Surgeon General's Office to publish the first surgeon general's report covering substance misuse and substance use disorders.

Quality of HIV Care and Mortality Rates in HIV-Infected Patients.

BACKGROUND: The Patient Protection and Affordable Care Act encourages healthcare systems to track quality-of-care measures; little is known about their impact on mortality rates. The objective of this study was to assess associations between HIV quality of care and mortality rates. METHODS: A longitudinal survival analysis of the Veterans Aging Cohort Study included 3038 human immunodeficiency virus (HIV)-infected patients enrolled between June 2002 and July 2008. The independent variable was receipt of ≥80% of 9 HIV quality indicators (QIs) abstracted from medical records in the 12 months after enrollment. Overall mortality rates through 2014 were assessed from the Veterans Health Administration, Medicare, and Social Security National Death Index records. We assessed associations between receiving ≥80% of HIV QIs and mortality rates using Kaplan-Meier survival analysis and adjusted Cox proportional hazards models. Results were stratified by unhealthy alcohol and illicit drug use. RESULTS: The majority of participants were male (97.5%) and black (66.8%), with a mean (standard deviation) age of 49.0 (8.8) years. Overall, 25.9% reported past-year unhealthy alcohol use and 28.4% reported past-year illicit drug use. During 24 805 person-years of follow-up (mean [standard deviation], 8.2 [3.3] years), those who received ≥80% of QIs experienced lower age-adjusted mortality rates (adjusted hazard ratio, 0.75; 95% confidence interval, .65-.86). Adjustment for disease severity attenuated the association. CONCLUSIONS: Receipt of ≥80% of select HIV QIs is associated with improved survival in a sample of predominantly male, black, HIV-infected patients but was insufficient to overcome adjustment for disease severity. Interventions to ensure high-quality care and address underlying chronic illness may improve survival in HIV-infected patients.

Number of Drinks to "Feel a Buzz" by HIV Status and Viral Load in Men.

The impact of HIV and its treatment on the effects of alcohol remain unclear. Blood alcohol concentrations have been noted to be higher in HIV infected individuals prior to antiretroviral initiation. Our goal was to compare number of drinks to "feel a buzz or high" among HIV infected and uninfected men, stratified by viral load (VL) suppression. Data includes 1478 HIV infected and 1170 uninfected men in the veterans aging cohort study who endorsed current drinking. Mean (SD) number of drinks to feel a buzz was 3.1 (1.7) overall. In multivariable analyses, HIV infected men reported a lower mean number of drinks to feel a buzz compared to uninfected men (coef = -14 for VL < 500; -34 for VL ≥ 500; p ≤ .05). Men with HIV, especially those with a detectable VL, reported fewer drinks to feel a buzz. Future research on the relationship between alcohol and HIV should consider the role of VL suppression.

Characteristics and engagement among English-language online forums for addiction recovery available in the US.

In developing public resources for the Networks Enhancing Addiction Recovery - Forum Activity Roadmap (NEAR-FAR), we completed a systematic observational study of English-language online forums related to recovery from alcohol or other drug addiction in late 2021. Among 207 identified forums, the majority were classified as "general addiction" or alcohol-focused, though classifications related to other substances were common on websites hosting multiple forums. Commonly used social media platforms such as Reddit, Facebook, or Quora offered easily accessible venues for individuals seeking online support related to a variety of substances. Forums were related to established recovery programs such as 12-step and SMART Recovery as well as other nonprofit and for-profit recovery programs, and to community forums without formal recovery programming. Among 148 forums with any observed user activity, the median time between unique user engagements was 27 days (inter-quartile range: 2-74). Among 98 forums with past-month posting activity, we found a median of <10 posts per week (inter-quartile range: 1-78). This study compares three metrics of observed forum activity (posts per week, responses per post, time between unique user engagements) and operationalizes forum characteristics that may potentiate opportunities for enhanced engagement and social support in addiction recovery.

Effect of hospital-level variation in the use of carotid artery stenting versus carotid endarterectomy on perioperative stroke and death in asymptomatic patients.

OBJECTIVE: Perioperative stroke and death (PSD) are more common after carotid artery stenting (CAS) than after carotid endarterectomy (CEA) in symptomatic patients, but whether this is also true in asymptomatic patients is unclear. Furthermore, use of both CEA and CAS varies geographically, suggesting possible variation in outcomes. We compared odds of PSD after CAS and CEA in asymptomatic patients to determine the impact of this variation. METHODS: We identified CAS and CEA procedures and hospitals where they were performed from 2005 to 2009 California hospital discharge data. Preoperative symptom status and medical comorbidities were determined using administrative codes. We compared PSD rates after CAS and CEA using logistic regression and propensity score matching. We quantified hospital-level variation in the relative utilization of CAS by calculating hospital-specific probabilities of CAS use among propensity score-matched patients. We then calculated a weighted average for each hospital and used this as a predictor of PSD. RESULTS: We identified 6053 CAS and 36,524 CEA procedures that were used to treat asymptomatic patients in 278 hospitals. Perioperative stroke and death occurred in 250 CAS and 660 CEA patients, yielding unadjusted PSD rates of 4.1% and 1.8%, respectively (P < .001). Compared with CAS patients, CEA patients were more likely to be older than 70 years (66% vs 62%; P < .001) but less likely to have three or more Elixhauser comorbidities (37% vs 39%; P < .001). Multivariate models demonstrated that CAS was associated with increased odds of PSD (odds ratio [OR], 1.865; 95% confidence interval [CI], 1.373-2.534; P < .001). Estimation of average treatment effects based on propensity scores also demonstrated 1.9% increased probability of PSD with CAS (P < .001). The average probability of receiving CAS across all hospitals and strata was 13.8%, but the interquartile range was 0.9% to 21.5%, suggesting significant hospital-level variation. In univariate analysis, patients treated at hospitals with higher CAS utilization had higher odds of PSD compared with patients in hospitals that performed CAS less (OR, 2.141; 95% CI, 1.328-3.454; P = .002). Multivariate analysis did not demonstrate this effect but again demonstrated higher odds of PSD after CAS (OR, 1.963; 95% CI, 1.393-2.765; P < .001). CONCLUSIONS: Carotid endarterectomy has lower odds of PSD compared with CAS in asymptomatic patients. Increased utilization of CAS at the hospital level is associated with increased odds of PSD among asymptomatic patients, but this effect appears to be related to generally worse outcomes after CAS compared with CEA.

Evaluation of VA Women's Health Fellowships: developing leaders in academic women's health.

BACKGROUND: The Department of Veterans Affairs (VA) instituted the VA Women's Health Fellowship (VAWHF) Program in 1994, to accommodate the health needs of increasing numbers of female veterans and to develop academic leaders in women's health. Despite the longevity of the program, it has never been formally evaluated. OBJECTIVE: To describe the training environments of VAWHFs and career outcomes of female graduates. DESIGN AND PARTICIPANTS: Cross-sectional web-based surveys of current program directors (2010-2011) and VAWHF graduates (1995-2011). RESULTS: Responses were received from six of seven program directors (86 %) and 42 of 74 graduates (57 %). The mean age of graduates was 41.2 years, and mean time since graduation was 8.5 years. Of the graduates, 97 % were female, 74 % trained in internal medicine, and 64 % obtained an advanced degree. Those with an advanced degree were more likely than those without an advanced degree to pursue an academic career (82 % vs. 60 %; P<0.01). Of the female graduates, 76 % practice clinical women's health and spend up to 66 % of their time devoted to women's health issues. Thirty percent have held a VA faculty position. Seventy-nine percent remain in academics, with 39 % in the tenure stream. Overall, 94 % had given national presentations, 88 % had received grant funding, 79 % had published in peer-reviewed journals, 64 % had developed or evaluated curricula, 51 % had received awards for teaching or research, and 49 % had held major leadership positions. At 11 or more years after graduation, 33 % of the female graduates in academics had been promoted to the rank of associate professor and 33 % to the rank of full professor. CONCLUSIONS: The VAWHF Program has been successful in training academic leaders in women's health. Finding ways to retain graduates in the VA system would ensure continued clinical, educational, and research success for the VA women veteran's healthcare program.

Comparing alcohol screening measures among HIV-infected and -uninfected men.

BACKGROUND: Brief measures of unhealthy alcohol use have not been well validated among people with HIV. We compared the Alcohol Use Disorders Identification Test (AUDIT) to reference standards for unhealthy alcohol use based on 30-day Timeline Follow Back (TLFB) and Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM), among 837 male HIV-infected and -uninfected patients in the Veterans Aging Cohort Study. METHODS: Three reference standards were (i) Risky drinking-based on TLFB >14 drinks over 7 consecutive days or >4 drinks on 1 day; (ii) Alcohol dependence-based on a CIDI-SAM diagnosis; and (iii) Unhealthy alcohol use-risky drinking or a CIDI-SAM diagnosis of abuse or dependence. Various cutoffs for the AUDIT, AUDIT-C, and heavy episodic drinking were compared with the reference standards. RESULTS: Mean age of patients was 52 years, 53% (444) were HIV-infected, and 53% (444) were African American. Among HIV-infected and -uninfected patients, the prevalence of risky drinking (14 vs. 12%, respectively), alcohol dependence (8 vs. 7%), and unhealthy alcohol use (22 vs. 20%) was similar. For risky drinking and alcohol dependence, multiple cutoffs of AUDIT, AUDIT-C, and heavy episodic drinking provided good sensitivity (≥80%) and specificity (≥90%). For unhealthy alcohol use, few cutoffs provided sensitivity ≥80%; however, many cutoffs provided good specificity. For all 3 alcohol screening measures, sensitivity improved when heavy episodic drinking was included with the cutoff. Sensitivity of measures for risky drinking and unhealthy alcohol use was lower in HIV-infected than in uninfected patients. CONCLUSIONS: For identifying risky drinking, alcohol dependence, and unhealthy alcohol use, AUDIT-C performs as well as AUDIT and similarly in HIV-infected and -uninfected patients. Cutoffs should be based on the importance of specific operating characteristics for the intended research or clinical use. Incorporating heavy episodic drinking increased sensitivity for detecting alcohol dependence and unhealthy alcohol use.

Perioperative all-cause mortality and cardiovascular events in patients with rheumatoid arthritis: comparison with unaffected controls and persons with diabetes mellitus.

OBJECTIVE: Rheumatoid arthritis (RA) is associated with an increased cardiovascular (CV) burden similar to that of diabetes mellitus (DM). This risk may warrant preoperative CV assessment as is performed for patients with DM. We aimed to determine whether the risks of perioperative death and CV events among patients with RA differed from those among unaffected controls and patients with DM. METHODS: We used 1998-2002 data from the Nationwide Inpatient Sample (NIS) database of the Healthcare Cost Utilization Project (HCUP) to identify hospitalizations of patients undergoing elective noncardiac surgery. Using established guidelines, surgical procedures were categorized as either low risk, intermediate risk, or high risk of having CV events. Logistic models provided the adjusted odds of study end points in patients with RA, DM, or both relative to patients with neither condition. RESULTS: Among 7,756,570 patients undergoing a low-risk, intermediate-risk, or high-risk noncardiac procedure, 2.34%, 0.51%, and 2.12%, respectively, had a composite CV event, and death occurred in 1.47%, 0.50%, and 2.59%, respectively. Among those undergoing an intermediate-risk procedure, death was less likely in RA patients than in DM patients (0.30% versus 0.65%; P < 0.001), but the difference in mortality rates among those undergoing low-risk versus high-risk procedures was not significant. Patients with RA were less likely to have a CV event than were patients with DM for procedures of low risk (3.38% versus 5.30%; P < 0.001) and intermediate risk (0.34% versus 1.07%; P < 0.001). In adjusted models, RA was not independently associated with an increased risk of perioperative death or a CV event. CONCLUSION: RA was not associated with adverse perioperative CV risk or mortality risk, which suggests that current perioperative clinical care does not need to be changed in this regard.

Characterizing online social support for alcohol use disorder: A mixed-methods approach.

BACKGROUND: Online social media communities are increasingly popular venues for discussing alcohol use disorder (AUD) and recovery. Little is known about distinct contexts of social support that are exchanged in this milieu, which are critical to understanding the social dynamics of online recovery support. METHODS: We randomly selected one post per day over the span of a year from the StopDrinking recovery forum. Direct responses to posts were double coded within an established theoretical framework of social support. Within a mixed-methods research framework, we quantified the linguistic characteristics of 1386 responses (i.e., text length, complexity, and sentiment) and qualitatively explored themes within and among different types of social support. RESULTS: Emotional support was most prevalent (74% of responses) and appeared as the sole form of support in 38% of responses. Emotionally supportive responses were significantly shorter, less complex, and more positively valenced than other support types. Appraisal support was also common in 55% of responses, while informational support was identified in only 17%. There was substantial overlap among support types, with 40% of responses including two or more types. Salient themes included the common use of community-specific acronyms in emotional support. Appraisal support conveyed feedback about attitudes and behaviors that are perceived as (un-) favorable for AUD recovery. Informational support responses were composed primarily of recommendations for self-help literature, clinical treatment approaches, and peer recovery programs. CONCLUSIONS: Social support in this sample was primarily emotional in nature, with other types of support included to provide feedback and guidance (i.e., appraisal support) and supplemental recovery resources (i.e., informational support). The provided social support framework can be helpful in characterizing community dynamics among heterogeneous online AUD recovery support forums. This framework could also be helpful in considering changes in support approaches that correspond to progress in recovery.

Hospitalized patients' acceptability of nurse-delivered screening, brief intervention, and referral to treatment.

BACKGROUND: Inpatient healthcare providers in the United States may soon be required to offer alcohol screening, brief intervention, and referral to treatment (SBIRT) for hospital accreditation, but little is known about inpatient acceptability for SBIRT, particularly when performed by nonphysician providers such as nurses. The purpose of this study was to assess patient acceptability for and comfort with nurse-delivered SBIRT care among hospitalized patients and to identify factors associated with SBIRT acceptability. METHODS: We conducted a cross-sectional survey of 370 hospitalized medical-surgical patients at a large university-affiliated medical center, which is part of the U.S. Department of Veterans Affairs. RESULTS: Patient acceptability for 8 of 10 individual nurse-delivered SBIRT tasks was >84%. Patients were more accepting of SBIRT tasks if they felt able to determine their alcohol risk, able to reduce alcohol-related health risks, and expressed some degree of concern about their own use of alcohol. Approximately 20% of patients reported some degree of personal discomfort with alcohol-related discussions. Patients who were less comfortable with these discussions had lower perceived ability to reduce alcohol-related health risk, were >60 years old, had a positive AUDIT-C screening, and were of nonblack race. CONCLUSIONS: Among hospitalized patients, patient acceptability for nurse-delivered SBIRT is high, and alcohol-related risk perceptions appear to be important factors associated with acceptability for SBIRT tasks. Providers can proceed with greater confidence in SBIRT-related discussions with most hospitalized patients but may need particular sensitivity and skill addressing alcohol with patient subgroups such as older patients and those with positive alcohol screenings.