"I Thought Cancer was a Tobacco Issue": Perspectives of Veterans with and without HIV on Cancer and Other Health Risks Associated with Alcohol and Tobacco/Nicotine Use.

U.S. Veterans and people living with HIV (PWH) experience higher rates of unhealthy alcohol and tobacco/nicotine use than non-Veterans and people without HIV (PWoH). Both groups are susceptible to adverse health outcomes associated with alcohol and tobacco/nicotine use. We explored awareness of alcohol- and tobacco/nicotine-related cancer and immune health risks among Veterans Health Administration (VA) patients with and without HIV. Among a sample of 41 (46% PWH; 73% male; 39% Black) purposively-selected VA patients receiving care 2020-2021 we conducted semi-structured interviews via telephone; interviews were recorded, transcribed and analyzed using a Rapid Assessment Process. Purposive selection was based on HIV status, alcohol and/or tobacco/nicotine use, and demographics. Among participants, 66% reported current smoking, and most screened positive for unhealthy alcohol use. Participants had high awareness of cancer and other health risks related to smoking but low awareness of synergistic risks and cancer risks associated with alcohol use despite awareness of a range of other alcohol-related risks. Awareness of alcohol and/or tobacco/nicotine's impacts on the immune system was variable. Findings did not distinctly differ between PWH and PWoH. Low awareness of alcohol-related cancer risk, risks of co-occurring use, and varying awareness of the impacts of alcohol and tobacco/nicotine on the immune system suggest a need for improved messaging regarding substance use-related cancer and immune risk. This may be especially important among PWH, for whom the prevalence and adverse effects of alcohol and tobacco use, and immune dysfunction are higher.

Receipt of Medications for Alcohol Use Disorder in the Veterans Health Administration: Comparison of Rates at the Intersections of Racialized and Ethnic Identity With Both Sex and Transgender Status.

OBJECTIVES: Medications for alcohol use disorder (MAUDs) are recommended for patients with alcohol use disorder yet are underprescribed. Consistent with Minority Stress and Intersectionality theories, persons with multiple sociodemographically marginalized identities (eg, Black women) often experience greater barriers to care and have poorer health outcomes. We use data from the Veterans Health Administration to assess disparities in Federal Drug Administration (FDA)-approved MAUDs and all effective MAUDs between the following groups: racialized and ethnic identity, sex, transgender status, and their intersections. METHODS: Among all Veterans Health Administration outpatients between August 1, 2015, and July 31, 2017, with documented alcohol screenings and an International Classification of Diseases diagnosis for alcohol use disorder in the 0-365 days prior (N = 308,238), we estimated the prevalence and 95% confidence intervals of receiving FDA-approved MAUDs and any MAUDs in the following year and compared them using χ2 or Fisher's exact test. Analyses are unadjusted to present true prevalence and group differences. RESULTS: The overall prevalence for MAUDs was low (FDA-MAUDs = 8.7%, any MAUDs = 20.0%). Within sex, Black males had the lowest rate of FDA-MAUDs (7.3%, [7.1-7.5]), whereas American Indian/Alaskan Native females had the highest (18.4%, [13.8-23.0]). Among those identified as transgender, Asian and Black transgender persons had the lowest rates of FDA-MAUDs (0%; 4.3%, [1.8-8.5], respectively), whereas American Indian/Alaskan Native transgender patients had the highest (33.3%, [2.5-64.1]). Similar patterns were observed for any MAUDs, with higher rates overall. CONCLUSIONS: Substantial variation exists in MAUD prescribing, with marginalized veterans disproportionately receiving MAUDs at lower and higher rates than average. Implementation and quality improvement efforts are needed to improve MAUD prescribing practices and reduce disparities.

Perspectives of clinical stakeholders and patients from four VA liver clinics to tailor practice facilitation for implementing evidence-based alcohol-related care.

BACKGROUND: Unhealthy alcohol use (UAU) is particularly dangerous for people with chronic liver disease. Liver clinics may be an important setting in which to provide effective alcohol-related care by integrating evidence-based strategies, such as brief intervention and medications for alcohol use disorder. We conducted qualitative interviews with clinical stakeholders and patients at liver clinics in four Veterans Health Administration (VA) medical centers to understand barriers and facilitators of integrating alcohol-related care and to support tailoring of a practice facilitation implementation intervention. METHODS: Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed and qualitatively analyzed using a Rapid Assessment Process (RAP) guided by the CFIR. RESULTS: We interviewed 46 clinical stakeholders and 41 patient participants and analyzed findings based on the CFIR. Clinical stakeholders described barriers and facilitators that ranged from operations/clinic resource-based (e.g., time and capacity, desire for additional provider types, referral processes) to individual perspective and preference-based (e.g., supportiveness of leadership, individual experiences/beliefs). Patient participants shared barriers and facilitators that ranged from relationship-based (e.g., trusting the provider and feeling judged) to resource and education-based (e.g., connection to a range of treatment options, education about impact of alcohol). Many barriers and facilitators to integrating alcohol-related care in liver clinics were similar to those identified in other clinical settings (e.g., time, resources, role clarity, stigmatizing beliefs). However, some barriers (e.g., fellow-led care and lack of integration of liver clinics with addictions specialists) and facilitators (e.g., presence of quality improvement staff in clinics and integrated pharmacists and behavioral health specialists) were more unique to liver clinics. CONCLUSIONS: These findings support the possibility of integrating alcohol-related care into liver clinics but highlight the importance of tailoring efforts to account for variation in provider beliefs and experiences and clinic resources. The barriers and facilitators identified in these interviews were used to tailor a practice facilitation implementation intervention in each clinic setting.

Prevalence of social and economic stressors among transgender veterans with alcohol and other drug use disorders.

Transgender persons have high rates of alcohol and other drug use disorders (AUD and DUD, respectively) and commonly experience social and economic stressors that may compound risk for adverse substance-related outcomes. National VA electronic health record data were extracted for all outpatients in each facility with documented alcohol screening 10/1/09-7/31/17. We describe the prevalence of eight individual-level social and economic stressors (barriers to accessing care, economic hardship, housing instability, homelessness, social and family problems, legal problems, military sexual trauma, and other victimization) among transgender patients with and without AUD and DUD (alone and in combination), overall and compared to cisgender patients in a national sample of VA outpatients. Among 8,872,793 patients, 8619 (0.1%) were transgender; the prevalence of AUD, DUD, and both was 8.6%, 7.2%, and 3.1% among transgender patients and 6.1%, 3.9%, and 1.7% among cisgender patients, respectively. Among all patients, prevalence of stressors was higher among those with AUD, DUD, or both, relative to those with neither. Within each of these groups, prevalence was 2-3 times higher among transgender compared to cisgender patients. For instance, prevalence of housing instability for transgender vs. cisgender patients with AUD, DUD, and both was: 40.8% vs 24.1%, 45.8% vs. 36.6%, and 57.4% vs. 47.0%, respectively. (all p-values <0.001). Social and economic stressors were prevalent among patients with AUD, DUD, or both, and the experience of these disorders and social and economic stressors was more common among transgender than cisgender patients in all groups. Further research regarding experiences of transgender persons and influences of stressors on risk of AUD and DUD, substance-related outcomes, and treatment uptake are needed. Routine screening for social and economic stressors among patients with substance use disorders (SUDs) could improve equitable substance-related care and outcomes. Treatment of SUDs among all persons should consider social and economic risk factors.

Comparison of Substance Use Disorder Diagnosis Rates From Electronic Health Record Data With Substance Use Disorder Prevalence Rates Reported in Surveys Across Sociodemographic Groups in the Veterans Health Administration.

Importance: Substance use disorders (SUDs) are major contributors to morbidity and mortality globally, but they are often underrecognized and underdiagnosed, particularly in some sociodemographic subgroups. Understanding the extent to which clinical diagnoses underestimate these conditions within subgroups is imperative to achieving equitable treatment, regardless of race, ethnicity, gender, or age, and to informing and improving performance monitoring. Objective: To compare clinically documented diagnosis rates of alcohol use disorder (AUD), drug use disorder (DUD), and total SUD (AUD and/or DUD) with the prevalence of these disorders as reported in surveys-based on structured, validated diagnostic assessments-across demographic subgroups. Design, Setting, and Participants: A telephone-based survey was conducted from January 8, 2018, to April 30, 2019, among 5995 Veterans Health Administration (VHA) outpatients who were randomly sampled from 30 VHA facilities and were 18 years of age or older, could complete the survey in English, and had a valid address and telephone number. Survey data were linked to electronic health record (EHR) data for all participants. Statistical analysis was performed between January 29, 2020, and April 20, 2021. Exposures: Demographic subgroups based on self-report: gender (male or female), age (18-34, 35-49, 50-64, 65-74, and ≥75 years), and race and ethnicity (Black non-Hispanic, Hispanic, multiracial, other [Asian or Asian-American, American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, and any other race endorsed by the participant], and White non-Hispanic). Main Outcomes and Measures: Survey-based prevalence rates of AUD, DUD, and SUD were assessed using the Mini International Neuropsychiatric Interview, version 7.0, the only validated instrument available at study outset that measured Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for past 12-month diagnoses. Clinically documented diagnosis rates were measured using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnoses from VHA EHR data. Analyses compared survey-based prevalence rates of AUD, DUD, and SUD with diagnosis rates using sensitivity and specificity and difference-in-difference analysis. All analyses were weighted with survey weights to account for nonresponse. Results: Of 5995 participants, 4115 (68.6%) were White non-Hispanic, and 5429 (91.1%) were male; the mean (SD) age was 61.5 (15.3) years. The survey-based prevalence rates of AUD, DUD, and SUD were higher than the diagnosis rates among all patients (AUD, 608 [10.1%] vs 360 [6.0%]; DUD, 282 [4.7%] vs 275 [4.6%]; SUD, 768 [12.8%] vs 515 [8.6%]). Survey-based prevalence rates of AUD and SUD exceeded the diagnosis rates in every demographic subgroup. Gaps between diagnosis rates and survey-based prevalence rates for AUD and SUD were largest among patients aged 18 to 34 years (AUD diagnosis rate, 27 [6.9%; 95% CI, 4.8%-9.9%] vs AUD prevalence rate, 88 [22.4%; 95% CI, 17.3%-28.5%]; SUD diagnosis rate, 41 [10.5%; 95% CI, 8.1%-13.4%] vs SUD prevalence rate, 109 [27.7%; 95% CI, 22.6%-33.3%]) and Hispanic and Latinx patients (AUD diagnosis rate, 31 [7.6%; 95% CI, 5.3%-10.8%] vs AUD prevalence rate, 72 [17.7%; 95% CI, 14.0%-22.1%]; and SUD diagnosis rate, 48 [11.7%; 95% CI, 7.9%-16.9%] vs SUD prevalence rate, 88 [21.6%; 95% CI, 18.0%-25.8%]). For DUD, only patients aged 18 to 34 years had a true prevalence rate that significantly exceeded the diagnosis rate (diagnosis rate, 21 [5.4%; 95% CI, 3.7%-7.8%] vs prevalence rate, 40 [10.1%; 95% CI, 7.2%-14.0%]). Conclusions and Relevance: The results of this survey study suggest that existing diagnostic procedures and tools are insufficient to capture SUD prevalence rates, particularly among younger patients and Hispanic and Latinx patients. Clinics and health systems should implement standardized SUD assessments to ensure the provision of equitable care and the optimal identification of underlying conditions for performance monitoring.

Patterns of Alcohol Use Among Transgender Patients Receiving Care at the Veterans Health Administration: Overall and Relative to Nontransgender Patients.

OBJECTIVE: Alcohol use is understudied among transgender persons--persons whose sex differs from their gender identity. We compare patterns of alcohol use between Veterans Health Administration (VA) transgender and nontransgender outpatients. METHOD: National VA electronic health record data were used to identify all patients' last documented Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screen (October 1, 2009-July 31, 2017). Transgender patients were identified using diagnostic codes. Logistic regression models estimated four past-year primary outcomes: (a) alcohol use (AUDIT-C > 0); (b) unhealthy alcohol use (AUDIT-C ≥ 5); (c) high-risk alcohol use (AUDIT-C ≥ 8); and (d) heavy episodic drinking (HED; ≥6 drinks on ≥1 occasion). Two secondary diagnostic-based outcomes, alcohol use disorder (AUD) and alcohol-specific conditions, were also examined. RESULTS: Among 8,872,793 patients, 8,619 (0.10%) were transgender. For transgender patients, unadjusted prevalence estimates were as follows: 52.8% for any alcohol use, 6.6% unhealthy alcohol use, 2.8% high-risk use, 10.4% HED, 8.6% AUD, and 1.3% alcohol-specific conditions. After adjustment for demographic characteristics, transgender patients had lower odds of patient-reported alcohol use but higher odds of alcohol-related diagnoses compared with nontransgender patients. Differences in alcohol-related diagnoses were attenuated after adjustment for comorbid conditions and utilization. CONCLUSIONS: This is the largest study of patterns of alcohol use among transgender persons and among the first to directly compare patterns to nontransgender persons. Findings suggest nuanced associations with patterns of alcohol use and provide a base for further disparities research to explore alcohol use within the diverse transgender community. Research with self-reported measures of gender identity and sex-at-birth and structured assessment of alcohol use and disorders is needed.

Practice facilitation to implement alcohol-related care in Veterans Health Administration liver clinics: a study protocol.

BACKGROUND: Alcohol-related care, including screening, brief intervention, and provision of/referral to medication or behavioral treatments for alcohol use disorder, could be delivered in liver clinics to better reach patients with chronic liver conditions. However, the provision of alcohol-related care in liver clinics is currently suboptimal. Practice facilitation is an evidence-based implementation strategy that may address barriers, harness facilitators, and optimize the implementation of alcohol-related care in liver clinic settings using a clinic-centered approach. We report the protocol of a study to test a practice facilitation intervention to implement alcohol-related care in four Veterans Health Administration liver clinics. METHODS: This study will employ a Hybrid Type 3 effectiveness-implementation design, in which implementation outcomes are considered primary and clinical outcomes secondary. Intervention and evaluation design were informed by the Consolidated Framework for Implementation Research. Qualitative data collected from clinical stakeholders and patients were used to tailor the intervention. The intervention involves a 6-month period of external practice facilitation, including regular meetings to identify clinic goals, challenges, and solutions; engagement of clinic champions; provision of training and development of educational materials for clinic staff and patients; and performance monitoring and feedback. Ongoing formative evaluation involves the collection of quantitative facilitator tracking data and qualitative data from meeting notes and patient interviews to describe intervention acceptability, feasibility, and adoption, and adjust implementation as needed. In the summative evaluation, implementation outcomes (clinic rates of screening, brief intervention, and treatment referral/receipt) and clinical outcomes (unhealthy alcohol use, liver health) will be assessed among patients in participating clinics using secondary electronic health record data and interrupted time series analysis. DISCUSSION: This will be the first study to our knowledge to test practice facilitation to implement alcohol-related care in liver clinic settings. Results from formative and summative evaluation will inform a framework for the successful implementation of effective alcohol-related care through practice facilitation in liver clinics, which may ultimately lead to better health outcomes for patients with chronic liver disease.

Attitudes toward alcohol use during pregnancy among women recruited from alcohol-serving venues in Cape Town, South Africa: A mixed-methods study.

BACKGROUND: The Western Cape Province of South Africa has one of the highest rates of fetal alcohol spectrum disorder (FASD) globally. Effective prevention of FASD requires understanding women's attitudes about alcohol use during pregnancy and whether these attitudes translate into behavior. OBJECTIVE: The goal of this mixed-methods study was to describe attitudes toward alcohol use during pregnancy and examine how these attitudes influence drinking behaviors during pregnancy. METHOD: Over a five month period, 200 women were recruited from alcohol-serving venues in a township in Cape Town; a sub-set of 23 also completed in-depth interviews. Potential gaps between attitudes and behavior were described, and logistic regression models examined predictors of harmful attitudes toward alcohol use during pregnancy. Interviews were reviewed and coded for emergent themes. RESULTS: Most women (n = 176) reported at least one pregnancy. Among these, the majority (83%) had positive preventive attitudes, but more than half of these still reported alcohol use during a previous pregnancy. The strongest predictors of harmful attitudes were a history of physical or sexual abuse and drinking during a previous pregnancy. Qualitative analysis revealed several themes that contributed to alcohol use during pregnancy: 1) having an unplanned pregnancy; 2) drinking because of stress or to cope with abuse/trauma; 3) reliance on the venue for support; 4) socialization; and 5) feelings of invincibility. CONCLUSIONS: The findings highlight an attitude-behavior gap and suggest that positive preventive attitudes are insufficient to elicit FASD preventive behavior. Interventions are needed that go beyond education to build intrinsic motivation and structural support to refrain from alcohol use during pregnancy.