Factors Underlying Quality Problems with Alcohol Screening Prompted by a Clinical Reminder in Primary Care: A Multi-site Qualitative Study.

BACKGROUND: Population-based alcohol screening is recommended in primary care, and increasingly incentivized by policies, yet is challenging to implement. The U.S. Veterans Health Administration (VA) achieved high rates of screening using a national performance measure and associated electronic clinical reminder to prompt and facilitate screening and document results. However, the sensitivity of alcohol screening for identifying unhealthy alcohol use is low in VA clinics. OBJECTIVE: We aimed to understand factors that might contribute to low sensitivity of alcohol screening. DESIGN: This was an observational, qualitative study. PARTICIPANTS: Participants included clinical staff responsible for conducting alcohol screening and nine independently managed primary care clinics of a single VA medical center in the Northwestern U.S. APPROACH: Four researchers observed clinical staff as they conducted alcohol screening. Observers took handwritten notes, which were transcribed and coded iteratively. Template analysis identified a priori and emergent themes. KEY RESULTS: We observed 72 instances of alcohol screening conducted by 31 participating staff. Observations confirmed known challenges to implementation of care using clinical reminders, including workflow and flexibility limitations. Three themes specific to alcohol screening emerged. First, most observed screening was conducted verbally, guided by the clinical reminder, although some variability in approaches to screening (e.g., paper-based or laminate-based screening) was observed. Second, specific verbal screening practices that might contribute to low sensitivity of clinical screening were identified, including conducting non-verbatim screening and making inferences, assumptions, and/or suggestions to input responses. Third, staff introduced and adapted screening questions to enhance patient comfort. CONCLUSIONS: This qualitative study in nine clinics found that implementation of alcohol screening facilitated by a clinical reminder resulted primarily in verbal screening in which questions were not asked vertbatim and were otherwise adapted. Non-verbal approaches to screening, or patient self-administration, may enhance validity and standardization of screening while simultaneously addressing limitations of the clinical reminder and issues related to perceived discomfort.

Prevalence and Trends of Concurrent Opioid Analgesic and Benzodiazepine Use Among Veterans Affairs Patients with Post-traumatic Stress Disorder, 2003-2011.

BACKGROUND: Patients with post-traumatic stress disorder (PTSD) have complex and multiple symptoms, including anxiety, insomnia, and co-occurring pain, often treated with opioids and benzodiazepines. While concurrent use of these medications poses safety concerns, little is known about the trends of long-term concurrent use and the prevalence of high-risk conditions among those who are prescribed them. Study objectives were to examine the trends in annual prevalence of long-term concurrent opioid and benzodiazepine use among patients with PTSD and prevalence of high-risk conditions in concurrent users of these medications. DESIGN: Retrospective review of pharmacy records of the Veteran Affairs Northwest Integrated Network (VISN20). SUBJECTS: Patients (n = 66,210) with PTSD receiving care during 2003-2011. METHODS: Concurrent use was defined as overlapping opioid and benzodiazepine prescriptions for ≥90 consecutive days. Gender-specific logistic regressions estimated long-term concurrent use of these medications and tested for linear trends over 9-years. RESULTS: The trend in age-adjusted long-term concurrent opioid and benzodiazepine use over 9-years increased 52.7%, from 3.6% (95% confidence interval, 3.3-3.9%) to 5.5% (5.3-5.8%), in men and 79.5%, from 3.9% (3.0-5.0%) to 7.0% (6.2-7.9%), in women. In 2011, 17.1% of long-term concurrent users were prescribed morphine-equivalent daily doses of opioids ≥100 mg and 49.4% had a documented high-risk condition. CONCLUSION: Despite known risks associated with prescribing opioids and benzodiazepines concurrently, the adjusted prevalence of long-term concurrent use rose significantly among men and women with PTSD in VISN20 over a 9-year period. Common use of these medications among patients with high-risk conditions suggests comprehensive strategies are needed to identify and monitor patients at increased risk for adverse outcomes.

The Hazardous Drinking Games Measure (HDGM): a multi-site implementation.

BACKGROUND: Drinking game participation has been associated with increased frequency and quantity of alcohol use, as well as alcohol-related problems, in college students. To date, the assessment of drinking games typically entails the use of self-developed measures of frequency of participation and amount of alcohol consumed while playing. OBJECTIVES: The Hazardous Drinking Games Measure (HDGM) is the first effort to create a comprehensive yet concise method of assessing drinking game participation. The HDGM assesses drinking during games, the specific types of drinking games played, and negative consequences experienced as a result of playing drinking games. METHOD: Data from three samples of college students (n = 1002) who completed the HDGM and other self-report questionnaires of drinking behaviors were used for exploratory analyses. RESULTS: Exploratory analyses suggest that the HDGM adequately captures the nuances of drinking game participation in this population and demonstrates initial evidence of good content and criterion-related validity and test-retest reliability. However, the HDGM did not predict risky drinking above and beyond standard measures of drinks per week and alcohol-related problems in any samples. CONCLUSION: The HDGM may be useful for campus-wide assessment of drinking games and as a source of game-specific feedback when integrated into campus prevention and intervention efforts.

Take One for the Team? Influence of Team and Individual Sport Participation on High School Athlete Substance Use Patterns.

The current web-based survey investigated the association between team or individual sport participation (or both) and self-reported alcohol and tobacco use among high school athletes (N=1, 275) transitioning to college. Peak Blood Alcohol Concentration, weekly drinking, and alcohol-related problems were significantly lower among athletes in individual sports compared to other groups. Athletes competing in both team and individual sports reported greater lifetime tobacco use and combined alcohol/tobacco use compared to individual or team sports alone. Preventive strategies targeting HS athletes in general and those participating in team sports in particular may be useful in minimizing future alcohol use and related problems.

Alcohol expectancies and risky drinking behaviors among high school athletes: "I'd rather keep my head in the game".

Research suggests that high school students who participate in sports may be at elevated risk for alcohol use compared to their non-athlete peers; however, reasons for this association are unclear. Alcohol expectancy theory posits that individuals who expect favorable outcomes to occur because of alcohol use are more likely to drink than those who do not endorse such beliefs. As such, the present study was designed to examine the associations of alcohol expectancy outcomes and valuations (i.e., beliefs about whether an outcome is good or bad), as well as alcohol expectancies related to sports functioning (e.g., alcohol's effects on one's ability to learn new plays and recover physically from sporting activities), with risky drinking among high school athletes. Participants were 219 in-season high school athletes (mean age = 15.6, range = 13-18) who completed anonymous self-report surveys. A structural equation model indicated that endorsement of positive alcohol expectancy outcomes and favorable evaluations of negative expectancy outcomes were associated with higher levels of risky drinking. Conversely, greater endorsement of negative athletic-functioning drinking expectancies was associated with lower levels of risky drinking. Future research considerations and implications for intervention efforts targeting high school athletes are discussed.

Evidence-based screening, diagnosis, and treatment of substance use disorders among veterans and military service personnel.

Substance use disorders (SUDs) are among the most common and costly conditions in veterans and active duty military personnel, adversely affecting their health and occupational and personal functioning. The pervasive burden of SUD has been a continuing concern for the Department of Veterans Affairs (VA) and Department of Defense (DoD), particularly as large numbers of service members return from Operations Enduring and Iraqi Freedom. The VA and DoD have prioritized implementation of evidence-based practices and treatment services to enhance the recognition and management of SUD in general medical and SUD specialty-care settings. This article summarizes the clinical practice guidelines for identifying, diagnosing, and treating SUD in VA and DoD general medical and SUD specialty-care settings, highlights evidence-based pharmacotherapy and psychosocial interventions for managing SUD, and describes barriers to successful treatment of veterans and service members at risk for SUD in VA and DoD health care systems.

Differences Between Athletes and Non-Athletes in Risk and Health Behaviors in Graduating High School Seniors.

Background: High school students involved in athletics may face additional stressors and engage in more problematic behaviors such as drinking, dieting, and gambling than non-athletes, especially as they near the end of their high school experience. Studies have in general found mixed results as to whether sports serve a protective factor or are a risk factor when it comes to a range of health behaviors. Method: This study evaluated 653 seniors in high school who were admitted to a large, public, west-coast University, during the spring prior to college entrance, and compared 513 Athletes to 140 non-Athletes across a range of health behaviors. Results: Those involved in sports were found to drink more than those who were not, and showed a trend for more gambling and dieting. Women athletes dieted significantly more than either male athletes or female non-athletes. Gender and ethnicity differences were found in health behaviors and were controlled for as covariates. Athletes were found to exercise more and spend less time playing video games and using the internet. Conclusions: Athletic involvement is associated with increased incidence of some risky health behaviors while also being associated with decreased incidence of other problematic behaviors. Implications for understanding and designing prevention and intervention efforts are discussed.

Do Parents Know Best? Examining the Relationship Between Parenting Profiles, Prevention Efforts, and Peak Drinking in College Students.

The study examined parent profiles among high school athletes transitioning to college and their association with high-risk drinking in a multi-site, randomized trial. Students (n = 587) were randomized to a control or combined parent-based and brief motivational intervention condition and completed measures at baseline and at 5- and 10-month follow-ups. Four parent profiles (authoritative, authoritarian, permissive, indifferent) were observed among participants. Findings indicated control participants with authoritarian parenting were at the greatest risk for heavy drinking. Alternately, students exposed to permissive or authoritarian parenting reported lower peak drinking when administered the combined intervention, compared to controls. Findings suggest the combined intervention was efficacious in reducing peak alcohol consumption among high-risk students based on athlete status and parenting profiles.

Is Substance Use a Team Sport? Attraction to Team, Perceived Norms, and Alcohol and Marijuana Use Among Male and Female Intercollegiate Athletes.

This research examined the role of attraction to one's team in predicting alcohol and marijuana use among intercollegiate athletes. Attraction to team and alcohol-related information were collected via an online survey and marijuana use-related information was gathered in a live setting. We investigated the influence of attraction to one's team above and beyond the influence of gender and perceived norms, and attraction to team as a moderator of these relationships. Attraction to one's team accounted for significant variance in marijuana use, and alcohol-related consequences after controlling for alcohol consumption. Regression analyses revealed significant interactions between gender, attraction to team, and norms in predicting alcohol and marijuana use. Stronger attraction to one's team may increase alcohol use but decrease marijuana use among male athletes, suggesting the importance of attraction to team when developing interventions for athletes.

Normative Misperceptions and Marijuana Use Among Male and Female College Athletes.

This research assessed the frequency of marijuana use and perceptions of gender-specific marijuana use among intercollegiate athletes from two National Collegiate Athletic Association (NCAA) Division 1 universities. Normative data were gathered in a live setting. Male athletes reported significantly greater marijuana use than female athletes and the overall sample reported higher prevalence of use than national averages for college athletes and non-athletes. Gender-specific perceptions among male and female athletes exceeded actual self-reported use, and perceived marijuana use among male athletes was strongly associated with personal use. The findings demonstrate the salience of group-specific marijuana norms and present implications for normative feedback interventions among college athletes.

Prevalence of Alcohol Misuse and Follow-Up Care in a National Sample of OEF/OIF VA Patients With and Without TBI.

OBJECTIVE: Information on prevalence and management of alcohol misuse among Afghanistan and Iraq veterans with traumatic brain injury (TBI) is limited. This study compared rates of alcohol misuse and follow-up care-brief intervention (BI) and addiction treatment-among Afghanistan and Iraq veterans with and without TBI receiving care from the Department of Veterans Affairs (VA). METHODS: The sample included veterans ages 18 and older screened with the Alcohol Use Disorders Identification Test alcohol consumption questions (AUDIT-C) in 2012 who received VA health care in the prior year (N=358,417). Overall and age-specific estimates of alcohol misuse (AUDIT-C score ≥5) were compared for men and women with and without TBI by logistic regression. BI and addiction treatment after screening were compared between groups by using multivariable logistic regression. RESULTS: Alcohol misuse was higher among men with TBI than among men without TBI (20.3%, 95% confidence interval [CI]=19.9-20.8, versus 16.4%, CI=16.3-16.6) and among women with TBI than among women without TBI (6.8%, CI=5.8-8.1, versus 5.6%, CI=5.4-5.8); younger (age <30) patients with TBI had the highest rates. BI rates did not differ by TBI status (76.4%-80.2%). Addiction treatment rates for those with severe misuse were higher among those with TBI (men, 20.0%, CI=18.4-21.6, versus 15.4%, CI=14.9-15.9; women, 36.6%, CI=21.8-51.3, versus 21.1%, CI=18.2-24.0). CONCLUSIONS: Alcohol misuse is common among Iraq and Afghanistan veterans with TBI, particularly young men. BI rates were high and did not vary by TBI status, although addiction treatment rates were higher among patients with TBI than among those without TBI.

Drinking norms, readiness to change, and gender as moderators of a combined alcohol intervention for first-year college students.

INTRODUCTION: Alcohol interventions targeting college students and their parents have been shown to be efficacious. Little research has examined moderators of intervention efficacy to help tailor interventions for subgroups of students. METHOD: This study is a secondary data analysis of readiness to change, drinking norms, and gender as moderators of an efficacious peer- and parent-based intervention (Turrisi et al., 2009). Students (n=680) were randomized to the combined peer and parent intervention (n=342) or assessment-only control (n=338). RESULTS: The combined intervention reduced peak blood alcohol content (BAC) compared to control. Gender and norms did not moderate the relationship between the intervention and drinking. Significant interactions were found between gender, precontemplation, and intervention. Students in the combined condition with higher precontemplation had lower weekly drinking compared to those with lower precontemplation. This pattern was also found among men for peak BAC and alcohol-related consequences but not among women, indicating a three-way interaction. CONCLUSION: Interventions may need to consider readiness to change and gender to optimize effectiveness.

Adverse Childhood Experiences, Military Service, and Adult Health.

INTRODUCTION: Prevalence of adverse childhood experiences (ACE) and associations with adult health may vary by gender and military service. This study compares the gender-specific prevalence of ACE by military service and determines the associations of ACE with adult health risk factors and health-related quality of life (HRQOL). METHODS: This 2014 analysis used data from the 2011 and 2012 CDC Behavioral Risk Factor Surveillance System. Total ACE was operationalized as the number of reported ACE. Associations of total ACE with adult health risk factors were estimated using general linear models; associations with HRQOL were estimated using negative binomial regression. All analyses adjusted for age and race/ethnicity. RESULTS: Those with military service had more total ACE than civilians. Higher ACE was associated with poorer HRQOL among women (physical health, military service, relative risk [RR]=1.20, 95% CI=1.09, 1.33; civilians, RR=1.18, 95% CI=1.17, 1.20; mental health, military service, RR=1.21, 95% CI=1.12, 1.32; civilians, RR=1.25, 95% CI=1.23, 1.26). Among men, these associations were somewhat attenuated in those with military service relative to civilians (physical health, military service, RR=1.13, 95% CI=1.09, 1.18; civilians, RR=1.20, 95% CI=1.17, 1.24; mental health, military service, RR=1.21, 95% CI=1.16, 1.27; civilians, RR=1.30, 95% CI=1.27, 1.34). CONCLUSIONS: Relative to civilians, men and women with military service report more ACE, but associations of ACE with adult HRQOL are weaker among men with military service relative to civilians. There is a need to implement and disseminate evidence-based programs to prevent ACE and for research on the long-term health consequences of ACE in military populations.

Clinical monitoring and high-risk conditions among patients with SUD newly prescribed opioids and benzodiazepines.

BACKGROUND: Opioid therapy alone or in combination with benzodiazepines poses safety concerns among patients with substance use disorders (SUD). Guidelines for opioid therapy recommend SUD treatment and enhanced monitoring, especially in patients with additional risk factors, but information on monitoring practices is sparse. This study estimated high-risk conditions - psychiatric comorbidity, suicide risk, and age <35 and ≥65 - and described clinical monitoring among patients with SUD who were newly prescribed opioids alone and concurrent with benzodiazepines long-term. METHODS: This study included VA Northwest Veterans Network patients with SUD who started opioids only (n=980) or benzodiazepines and opioids concurrently (n=353) long-term (≥90 days) in 2009-2010. Clinical characteristics, outpatient visits and urine drug screens (UDS) documented within 7-months after starting medications were extracted from VA data. RESULTS: Approximately 67% (95% CI: 64-70) of opioids only and 94% (92-97) of concurrent medications groups had ≥1 psychiatric diagnoses. Prevalences of suicide risk and age <35 and ≥65 were 7% (5-8), 6% (5-8) and 18% (15-20) among the opioids only group, and 20% (16-24), 8% (5-11) and 13% (9-16) among the concurrent medications group. Among patients prescribed opioids only and medications concurrently, 87% and 91% attended primary care, whereas 28% and 26% attended SUD specialty-care. Overall, 30% and 48% of opioids only and concurrent medications groups engaged in mental health or SUD care, and 35% and 39% completed UDS. CONCLUSIONS: Improvements in clinical monitoring are needed as many VA patients with SUD and comorbid risks who initiate opioid therapy do not receive sufficient mental health/SUD care or UDS monitoring.

Decreasing sensitivity of clinical alcohol screening with the AUDIT-C after repeated negative screens in VA clinics.

BACKGROUND: Routine screening for unhealthy alcohol use is widely recommended in primary care settings. However, the validity of repeat screening among patients who have previously screened negative remains unknown. This study aims to evaluate the performance of a clinical alcohol screen compared to a confidential comparison alcohol screen among patients with previous negative alcohol screens. METHODS: This study included four nested samples of Veteran Health Administration (VA) outpatients with at least one (N=18,493) and up to four (N=714) prior negative annual clinical AUDIT-C screens who completed the AUDIT-C the following year, both in a VA clinic (clinical screen) and on a confidential mailed survey (comparison screen). AUDIT-C screens were categorized as either negative (0-3 points men; 0-2 women) or positive (≥4 men; ≥3 women). For each sample, the performance of the clinical screen was compared to the comparison screen, the reference measure for unhealthy alcohol use. RESULTS: The sensitivity of clinical screens decreased as the number of prior negative screens in a sample increased (40.0-17.4%) for patients with 1-4 negative screens. The positive predictive value also decreased as the number of prior negative screens in a sample increased (67.7-33.3%) while specificity was consistently high for all samples (≥97.8%). CONCLUSIONS: Repeat clinical alcohol screens became progressively less sensitive for identifying unhealthy alcohol use among patients who repeatedly screened negative over several years. Alternative approaches for assessing unhealthy alcohol use may be needed for these patients.

Prevalence of clinically recognized alcohol and other substance use disorders among VA outpatients with unhealthy alcohol use identified by routine alcohol screening.

OBJECTIVE: The purpose of routine alcohol screening is to identify patients who may benefit from brief intervention, but patients who also have alcohol and other substance use disorders (AUD/SUD) likely require more intensive interventions. This study sought to determine the prevalence of clinically documented AUD/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 (diagnosis of AUD, SUD, or alcohol-specific medical conditions, or VA specialty addictions treatment on the date of or 365 days prior to screening) were estimated and compared across AUDIT-C risk groups, and then repeated 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 with increasing 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 similar across age groups. CONCLUSIONS: One-quarter of all patients with unhealthy alcohol use, and a majority of those with the highest alcohol screening scores, had clinically recognized AUD/SUD. Healthcare systems implementing evidence-based alcohol-related care should be prepared to offer more intensive interventions and/or effective pharmacotherapies for these patients.

Comparative safety of benzodiazepines and opioids among veterans affairs patients with posttraumatic stress disorder.

OBJECTIVES: Although Veterans Affairs (VA) patients with posttraumatic stress disorder (PTSD) are prescribed benzodiazepines and opioids in addition to recommended pharmacotherapies, little is known about the safety of these medications. This study compared the 2-year incidence of adverse events among VA patients with PTSD exposed to combinations of selective serotonin reuptake inhibitors (SSRIs) or serotonin/norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, and opioids. METHODS: This retrospective cohort study used VA administrative data from 2004 to 2010 to identify and follow 5236 VA patients with PTSD with new episodes of (1) SSRIs/SNRIs only; (2) concurrent SSRIs/SNRIs and benzodiazepines; and (3) concurrent SSRIs/SNRIs, benzodiazepines, and opioids. Outcome measures were the 2-year incidence and adjusted hazard ratios (AHR) of mental health and medicine/surgery hospitalizations, emergency department visits, harmful events (eg, injuries and death), and any adverse event after adjustment for demographics, clinical covariates, and adverse event history. RESULTS: Compared with SSRIs/SNRIs only, the adjusted risk of mental health hospitalizations (AHR: 1.87; 95% confidence interval [CI]: 1.37-2.53) was greater among patients prescribed SSRIs/SNRIs and benzodiazepines concurrently. The AHR of mental health hospitalizations (AHR: 2.00; 95% CI: 1.35-2.98), medicine/surgery hospitalizations (AHR: 4.86; 95% CI: 3.30-7.14), emergency department visits (AHR: 2.01; 95% CI: 1.53-2.65), any harmful event (2.92; 95% CI: 2.21-3.84), and any adverse event (AHR: 2.65; 95% CI: 2.18-3.23) were all significantly greater among patients prescribed SSRIs/SNRIs, benzodiazepines, and opioids than among those prescribed SSRIs/SNRIs only. CONCLUSIONS: Concurrently prescribing SSRIs/SNRIs, benzodiazepines, and opioids among patients with PTSD is associated with adverse events. Although efforts are warranted to monitor patients who are prescribed combinations of these medications to prevent adverse events, these results should be interpreted with caution until they are replicated.

Relationships among veteran status, gender, and key health indicators in a national young adult sample.

OBJECTIVE: Although many risk behaviors peak during young adulthood, little is known about health risk factors and access to care. This study assessed health indicators and health care access in a national sample of young adult veterans and civilians. METHODS: Data were from the 2010 Behavioral Risk Factor Surveillance System, a national telephone survey. Of 27,471 participants, ages 19-30 years, 2.2% were veterans (74.6% were male) and 97.7% were civilians (37.6% were male). Gender-stratified comparisons assessed health indicators and health care access by veteran status. Multivariate logistic regression was used to examine health indicators and health care access as a function of gender and veteran status. RESULTS: In the overall sample, women were more likely than men to have insurance, to have a regular physician, and to have had a routine checkup and yet were more likely to report financial barriers to care. Women also were more likely than men to report general medical and mental distress and higher lifetime anxiety and depressive disorders, whereas men were more likely to be overweight or obese and to report tobacco use and high-risk drinking. Adjusted analyses revealed a higher likelihood of general medical distress and higher rates of lifetime anxiety disorders among veterans compared with civilians, although there were no differences between veterans and civilians regarding health care utilization and hazardous drinking. CONCLUSIONS: Findings extend the literature on health care status and modifiable risk factors for young adults by identifying differences between men and women and between veterans and civilians. Interventions may need to be tailored on the bases of gender and veteran status because of several differences in mental health and general health needs.

Characterizing high school students who play drinking games using latent class analysis.

Heavy alcohol use and its associated negative consequences continue to be an important health issue among adolescents. Of particular concern are risky drinking practices such as playing drinking games. Although retrospective accounts indicate that drinking game participation is common among high school students, it has yet to be assessed in current high school students. Utilizing data from high school students who reported current drinking game participation (n=178), we used latent class analysis to investigate the negative consequences resulting from gaming and examined underlying demographic and alcohol-related behavioral characteristics of students as a function of the resultant classes. Three classes of "gamers" emerged: (1) a "lower-risk" group who had a lower probability of endorsing negative consequences compared to the other groups, (2) a "higher-risk" group who reported that they experienced hangovers and difficulties limiting their drinking, got physically sick, and became rude, obnoxious, or insulting, and (3) a "sexual regret" group who reported that they experienced poor recall and unplanned sexual activity that they later regretted. Although the frequency of participating in drinking games did not differ between these three groups, results indicated that the "lower-risk" group consumed fewer drinks in a typical gaming session compared to the other two groups. The present findings suggest that drinking games are common among high school students, but that mere participation and frequency of play are not necessarily the best indicators of risk. Instead, examination of other constructs such as game-related alcohol consumption, consequences, or psychosocial variables such as impulsivity may be more useful.

Follow-up care for alcohol misuse among OEF/OIF veterans with and without alcohol use disorders and posttraumatic stress disorder.

Little is known about follow-up care for alcohol misuse in the Veterans Affairs (VA) health care system among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans with and without alcohol use disorders (AUD) and/or posttraumatic stress disorder (PTSD). Using data from 4725 OEF/OIF VA outpatients with alcohol screening (2006-2010), we compared the prevalence of follow-up for alcohol misuse--brief intervention (BI) or referral to treatment--among patients with and without AUD and/or PTSD. Among 933 (19.7%) patients with alcohol misuse (AUDIT-C ≥5), 77.0% had AUD and/or PTSD. Rates of BI or referral for alcohol misuse were higher among patients with AUD (76.9%) and both AUD and PTSD (70.1%) compared to those with PTSD only (53.1%) and neither AUD nor PTSD (52.3%). Among OEF/OIF VA outpatients with alcohol misuse, those with AUD had higher rates of follow-up for alcohol misuse than those without, but PTSD was not associated with differential follow-up.