Abstract
Alcohol screening may be associated with health outcomes that cluster with alcohol use (ie, alcohol-clustering conditions), including depression, anxiety, and use of tobacco, marijuana, and illicit drugs. To quantify the extent to which alcohol screening provides additional information regarding alcohol-clustering conditions and to compare 2 alcohol use screening tools commonly used for this purpose. This longitudinal cohort study used data from the Veterans Aging Cohort Study. Data were collected at 8 Veterans Health Administration facilities from 2003 through 2012. A total of 7510 participants were enrolled, completed a baseline survey, and were followed up. Veterans with HIV were matched with controls without HIV by age, race, sex, and site of care. Data were analyzed from January 2019 to December 2019. The Alcohol Use Disorders Identification Test (AUDIT) and Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) were used to assess alcohol use, with 4 risk groups delineated for each test: score 0 to 7 (reference), score 8 to 15, score 16 to 19, and score 20 to 40 (maximum score) for the full AUDIT and score 0 to 3 (reference), score 4 to 5, score 6 to 7, and score 8 to 12 (maximum score) for the AUDIT-C. Alcohol-clustering conditions, including self-reported symptoms of depression and anxiety and use of tobacco, marijuana, cocaine, other stimulants, opioids, and injection drugs. A total of 6431 US patients (6104 [95%] men; median age during survey years 2003-2004, 50 years [range, 28-86 years; interquartile range, 44-55 years]) receiving care in the Veterans Health Administration completed 1 or more follow-up surveys when the AUDIT was administered and were included in the present analyses. Of the male participants, 4271 (66%) were African American, 1498 (24%) were white, and 590 (9%) were Hispanic. The AUDIT and AUDIT-C scores were associated with each alcohol-clustering condition. In particular, an AUDIT score of 20 or higher (vs <8, the reference) was associated with symptoms of depression (odds ratio [OR], 8.37; 95% CI, 6.20-11.29) and anxiety (OR, 8.98; 95% CI, 6.39-12.60) and with self-reported use of tobacco (OR, 14.64; 95% CI, 8.94-23.98), marijuana (OR, 12.41; 95% CI, 8.61-17.90), crack or cocaine (OR, 39.47; 95% CI, 27.38-56.90), other stimulants (OR, 21.31; 95% CI, 12.73-35.67), and injection drugs (OR, 8.67; 95% CI, 5.32-14.13). An AUDIT score of 20 or higher yielded likelihood ratio (sensitivity / 1 - specificity) values greater than 3.5 for depression, anxiety, crack or cocaine use, and other stimulant use. Associations between AUDIT-C scores and alcohol-clustering conditions were more modest. Alcohol screening can inform decisions about further screening and diagnostic assessment for alcohol-clustering conditions, particularly for depression, anxiety, crack or cocaine use, and other stimulant use. Future studies using clinical diagnoses rather than screening tools to assess alcohol-clustering conditions may be warranted.
Highlights
Unhealthy alcohol use encompasses a range of alcohol use patterns, from risky use, which is defined as exceeding the recommended daily drinking limits,[3] to harmful use, which is accompanied by alcohol-related consequences, and dependence, which is accompanied by substantial impairment.[4]
If corroborated by future studies, our results suggest that guideline panels should consider whether an expanded scope for the Alcohol Use Disorders Identification Test (AUDIT) and Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) is warranted given their utility in informing the index of suspicion for other alcoholclustering conditions
Our findings underscore the potential for alcohol screening, which is recommended as a standard practice in most primary care settings, to provide an additional benefit of identifying patients with a high risk of other clinical conditions
Summary
The health consequences of alcohol use are substantial, with rates of alcohol use having increased dramatically in the most recent reporting periods.[1,2] Unhealthy alcohol use encompasses a range of alcohol use patterns, from risky use, which is defined as exceeding the recommended daily drinking limits (ie, >3 drinks per day for women and >4 drinks per day for men),[3] to harmful use, which is accompanied by alcohol-related consequences (eg, failure to fulfill obligations or interpersonal problems), and dependence, which is accompanied by substantial impairment (eg, tolerance, withdrawal, or inability to reduce alcohol consumption).[4] In the US, the most recent estimates suggest that 13% of adults exceed recommended daily drinking limits on a weekly basis, representing a 30% increase over a 10-year period, and an additional 13% have alcohol use disorder,[1] representing a 50% increase over the course of 10 years.[1] Globally, alcohol use disorder is the most common substance use disorder, with estimates indicating a worldwide population of 100 million individuals with alcohol use disorder.[2] Current guidelines suggest annual screening and treatment or referral for unhealthy alcohol use in adult primary care settings in an effort to reduce alcohol use–related morbidity and mortality.[5,6] In many health care systems, alcohol screening is integrated into routine primary care.[7,8]
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