High test-retest reliability of the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire completed by primary care patients in routine care.

BACKGROUND: The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is a three-item screening measure of unhealthy alcohol use that is widely used in healthcare settings. Evidence shows high test-retest reliability of the AUDIT-C in research samples, but most studies had limited external validity and used small samples that could not be used to evaluate reliability across demographic subgroups and/or screening modalities. This study evaluates the test-retest reliability of the AUDIT-C completed in routine care in a large primary care sample, including across demographic subgroups defined by age, sex, race, ethnicity, and screening modality (i.e., completed in-clinic or online). METHODS: We used electronic health record (EHR) data from Kaiser Permanente Washington. The sample included 18,491 adult primary care patients who completed two AUDIT-C screens 1-21 days apart as part of routine care in 2021. Test-retest reliability was evaluated for AUDIT-C total scores (0-12) and for a binary measure indicating unhealthy alcohol use (scores ≥3 women, ≥4 men). Using previously established cutoffs, we interpreted reliability coefficients >0.75 as indicating "excellent" reliability. RESULTS: AUDIT-C screens completed in routine care and documented in EHRs had excellent test-retest reliability for total scores (ICC = 0.87, 95% CI: 0.87-0.87) and the binary indicator of unhealthy alcohol use (κ = 0.79, 95% CI: 0.78-0.80). Reliability coefficients were good to excellent across all demographic groups and for in-clinic and online modalities. Higher reliability was seen when both screens were completed through online patient portals (ICC = 0.93, 95% CI: 0.93-0.93) versus in-clinic (ICC = 0.81, 95% CI: 0.79-0.82) or when one screen was completed using each modality (ICC = 0.83, 95% CI: 0.82-0.83). Lower reliability was seen in American Indian/Alaska Native (ICC = 0.82, 95% CI: 0.75-0.87) and multiracial individuals (ICC = 0.82, 95% 0.80-0.84). CONCLUSIONS: In real-world routine care conditions, AUDIT-C screens have excellent test-retest reliability across demographic subgroups and modalities (online and in-clinic). Future research should examine why reliability varies slightly across modalities and demographic subgroups.

Effect of lowering initiation thresholds in a primary care-based buprenorphine treatment program.

BACKGROUND: Office-based buprenorphine treatment is effective for opioid use disorder. Scant research has examined programmatic factors impacting successful initiation of treatment. To increase initiation of eligible patients, our buprenorphine program implemented changes to lower treatment thresholds. Most notable among these was elimination of a requirement that patients demonstrate abstinence from stimulants prior to initiating buprenorphine. METHODS: This observational, retrospective study included patients screened for primary care-based buprenorphine treatment under high- and low-threshold conditions from 2015 to 2017. Background characteristics and treatment data were extracted from the electronic medical record and clinical registry. Chi-squared tests were used to compare proportions of patients initiated within 90 days of screening and retained to 60 days after initiation, under both conditions. Multivariate logistic regression was employed to compare relative odds of buprenorphine initiation after adjustment for several covariates. All analyses were stratified by recent stimulant use. RESULTS: The sample of 168 patients included 96 in the high-threshold group and 72 in the low-threshold group. Among patients with recent stimulant use, low-threshold conditions were associated with a higher proportion of patients initiated (69% versus 35%, p = 0.002) and higher relative odds of initiation (aOR = 7.01, 95% CI = 2.26-21.80) but also with a lower proportion of patients retained (63% versus 100%, p = 0.004). Among patients without recent stimulant use, low-threshold conditions did not change these measures by a statistically significant margin. CONCLUSIONS: Lower-threshold policies may increase buprenorphine treatment initiation for patients with co-occurring stimulant use. However, patients using stimulants may require additional supports to remain engaged.

Linking patients with buprenorphine treatment in primary care: Predictors of engagement.

BACKGROUND: Office-based buprenorphine treatment promises to expand effective treatment for opioid use disorder. Unfortunately, patients may be lost during engagement, before induction with medication. Few data are available regarding rates and predictors of successfully reaching induction. METHODS: The sample included 100 consecutive patients seeking treatment in 2016 at an office-based buprenorphine treatment program in an urban, academic primary care clinic. Patients completed phone intake, nurse visit and physician visit prior to induction. We reviewed electronic medical records to describe the time to complete each step and used multivariable logistic regression to identify predictors of reaching induction. RESULTS: Sixty percent of the sample dropped out prior to induction, with the majority dropping out prior to the nurse visit. For patients who successfully completed induction, median time between screening and induction was 18days (interquartile range 13-30days). After adjustment for other factors, completing induction was significantly less likely in patients with recent polysubstance use (OR=0.15, 95% CI=0.04-0.53), prior methadone treatment (OR=0.05, 95% CI=0.01-0.36), prior buprenorphine treatment (OR=0.60, 95% CI=0.01-0.47), or other prior treatment (OR=0.19, 95% CI=0.04-0.98). Sociodemographic characteristics, such as younger age, minority race/ethnicity, homelessness, unemployment, history of incarceration and relationship status were not significant predictors. CONCLUSIONS: Over half of patients beginning primary care buprenorphine treatment were not successful in starting medication. Those with polysubstance use or previous substance use treatment were least likely to be successful. Programs should carefully consider barriers that might prevent treatment-seeking patients from starting medications. Some patients might need enhanced support to successfully start treatment with buprenorphine.