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1.  Rationale and Methods of the Substance Use and Psychological Injury Combat Study (SUPIC): A Longitudinal Study of Army Service Members Returning from Deployment in FY2008–2011 
Substance use & misuse  2013;48(10):863-879.
SUPIC will examine whether early detection and intervention for post-deployment problems among Army Active Duty and National Guard/Reservists returning from Iraq or Afghanistan are associated with improved long-term substance use and psychological outcomes. This paper describes the rationale and significance of SUPIC, and presents demographic and deployment characteristics of the study sample (N=643,205), and self-reported alcohol use and health problems from the subsample with matched post-deployment health assessments (N=487,600). This longitudinal study aims to provide new insight into the long-term post-deployment outcomes of Army members by combining service member data from the Military Health System and Veterans Health Administration.
PMCID: PMC3793632  PMID: 23869459
Military Health System; deployment; observational study design; outcomes; urinanalysis; active duty; National Guard/Reservists; veterans; alcohol use disorder; posttraumatic stress disorder; depression
2.  Establishing the Feasibility of Measuring Performance in Use of Addiction Pharmacotherapy 
This paper presents the rationale and feasibility of standardized performance measures for use of pharmacotherapy in the treatment of substance use disorders (SUD), an evidence-based practice and critical component of treatment that is often underused. These measures have been developed and specified by the Washington Circle, to measure treatment of alcohol and opioid dependence with FDA-approved prescription medications for use in office-based general health and addiction specialty care. Measures were pilot tested in private health plans, the Veterans Health Administration (VHA), and Medicaid. Testing revealed that use of standardized measures using administrative data for overall use and initiation of SUD pharmacotherapy is feasible and practical. Prevalence of diagnoses and use of pharmacotherapy varies widely across health systems. Pharmacotherapy is generally used in a limited portion of those for whom it might be indicated. An important methodological point is that results are sensitive to specifications, so that standardization is critical to measuring performance across systems.
PMCID: PMC3954716  PMID: 23490233
performance measurement; pharmacotherapy; addiction medication; Veterans Health; Medicaid
3.  Associations Between AUDIT-C and Mortality Vary by Age and Sex 
Population Health Management  2010;13(5):263-268.
We sought to determine the sex- and age-specific risk of mortality associated with scores on the 3-item Alcohol Use Disorder Identification Test–Consumption (AUDIT-C) questionnaire using data from a national sample of Veterans Health Administration (VHA) patients. Men (N = 215,924) and women (N = 9168) who completed the AUDIT-C in a patient survey were followed for 24 months. AUDIT-C categories (0, 1–4, 5–8, 9–12) were evaluated as predictors of mortality in logistic regression models, adjusted for age, race, education, marital status, smoking, depression, and comorbidities. For women, AUDIT-C scores of 9–12 were associated with a significantly increased risk of death compared to the AUDIT-C 1-4 group (odds ratio [OR] 7.09; 95% confidence interval [CI] = 2.67, 18.82). For men overall, AUDIT-C scores of 5–8 and 9–12 were associated with increased risk of death compared to the AUDIT-C 1-4 group (OR 1.13, 95% CI = 1.05, 1.21, and OR 1.63, 95% CI = 1.45, 1.84, respectively) but these associations varied by age. These results provide sex- and age-tailored risk information that clinicians can use in evidence-based conversations with patients about the health-related risks of their alcohol consumption. This study adds to the growing literature establishing the AUDIT-C as a scaled marker of alcohol-related risk or “vital sign” that might facilitate the detection and management of alcohol-related risks and problems. (Population Health Management 2010;13:263–268)
PMCID: PMC3135896  PMID: 20879907
4.  Association between Alcohol Screening Scores and Mortality in Black, Hispanic, and White Male Veterans 
AUDIT-C alcohol screening scores are associated with mortality, but whether or how associations vary across race/ethnicity is unknown.
Self-reported black (n=13,068), Hispanic (n=9,466), and white (n=182,688) male VA outpatients completed the AUDIT-C via mailed survey. Logistic regression models evaluated whether race/ethnicity modified the association between AUDIT-C scores (0, 1–4, 5–8, and 9–12) and mortality after 24 months, adjusting for demographics, smoking, and comorbidity.
Adjusted mortality rates were 0.036, 0.033, and 0.054, for black, Hispanic, and white patients with AUDIT-C scores of 1–4, respectively. Race/ethnicity modified the association between AUDIT-C scores and mortality (p=0.0022). Hispanic and white patients with scores of 0, 5–8, and 9–12 had significantly increased risk of death compared to those with scores of 1–4; Hispanic ORs: 1.93, 95% CI 1.50–2.49; 1.57, 1.07–2.30; 1.82, 1.04–3.17, respectively; white ORs: 1.34, 95% CI 1.29–1.40; 1.12, 1.03–1.21; 1.81, 1.59–2.07, respectively. Black patients with scores of 0 and 5–8 had increased risk relative to scores of 1–4 (ORs 1.28, 1.06–1.56 and 1.50, 1.13–1.99), but there was no significant increased risk for scores of 9–12 (ORs 1.27, 0.77–2.09). Post-hoc exploratory analyses suggested an interaction between smoking and AUDIT-C scores might account for some of the observed differences across race/ethnicity.
Among male VA outpatients, associations between alcohol screening scores and mortality varied significantly depending on race/ethnicity. Findings could be integrated into systems with automated risk calculators to provide demographically-tailored feedback regarding medical consequences of drinking.
PMCID: PMC3443543  PMID: 22676340
alcohol; race; ethnicity; mortality; AUDIT-C
5.  Alcohol Screening Scores and the Risk of New-Onset Gastrointestinal Illness or Related Hospitalization 
Excessive alcohol use is associated with a variety of negative health outcomes, including liver disease, upper gastrointestinal bleeding, and pancreatitis.
To determine the 2-year risk of gastrointestinal-related hospitalization and new-onset gastrointestinal illness based on alcohol screening scores.
Retrospective cohort study.
Male (N = 215, 924) and female (N = 9,168) outpatients who returned mailed questionnaires and were followed for 24 months.
Alcohol Use Disorder Identification Test—Consumption Questionnaire (AUDIT-C), a validated three-item alcohol screening questionnaire (0–12 points).
Two-year risk of hospitalization with a gastrointestinal disorder was increased in men with AUDIT-C scores of 5–8 and 9–12 (OR 1.54, 95% CI = 1.27–1.86; and OR 3.27; 95% CI = 2.62–4.09 respectively), and women with AUDIT-C scores of 9–12 (OR 6.84, 95% CI = 1.85 – 25.37). Men with AUDIT-C scores of 5–8 and 9–12 had increased risk of new-onset liver disease (OR 1.49, 95% CI = 1.30–1.71; and OR 2.82, 95% CI = 2.38–3.34 respectively), and new-onset of upper gastrointestinal bleeding (OR 1.28, 95% CI = 1.05–1.57; and OR 2.14, 95% CI = 1.54-2.97 respectively). Two-year risk of new-onset pancreatitis in men with AUDIT -C scores 9–12 was also increased (OR 2.14; 95% CI = 1.54–2.97).
Excessive alcohol use as determined by AUDIT-C is associated with 2-year increased risk of gastrointestinal-related hospitalization in men and women and new-onset liver disease, upper gastrointestinal bleeding, and pancreatitis in men. These results provide risk information that clinicians can use in evidence-based conversations with patients about their alcohol consumption.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1688-7) contains supplementary material, which is available to authorized users.
PMCID: PMC3138581  PMID: 21455813
alcohol; AUDIT; gastrointestinal; hospitalization; new-onset; women
6.  Alcohol Screening and Risk of Postoperative Complications in Male VA Patients Undergoing Major Non-cardiac Surgery 
Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed.
To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire—up to a year before surgery—were associated with the risk of postoperative complications.
This is a cohort study.
Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA’s Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery.
One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews.
Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8–6.6%) in patients with AUDIT-C scores 1–4, to 7.9% (6.3–9.7%) in patients with AUDIT-Cs 5–8, 9.7% (6.6–14.1%) in patients with AUDIT-Cs 9–10 and 14.0% (8.9–21.3%) in patients with AUDIT-Cs 11–12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1–5.7%) in patients with AUDIT-C scores 1–4, to 6.9% (5.5–8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0–11.3%) among those with AUDIT-Cs 9–10.
AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1475-x) contains supplementary material, which is available to authorized users.
PMCID: PMC3019325  PMID: 20878363
alcohol screening; surgical outcomes; AUDIT-C
7.  Risk of future trauma based on alcohol screening scores: A two-year prospective cohort study among US veterans 
Severe alcohol misuse as measured by the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) is associated with increased risk of future fractures and trauma-related hospitalizations. This study examined the association between AUDIT-C scores and two-year risk of any type of trauma among US Veterans Health Administration (VHA) patients and assessed whether risk varied by age or gender.
Outpatients (215, 924 male and 9168 female) who returned mailed AUDIT-C questionnaires were followed for 24 months in the medical record for any International Statistical Classification of Diseases and Related Health Problems (ICD-9) code related to trauma. The two-year prevalence of trauma was examined as a function of AUDIT-C scores, with low-level drinking (AUDIT-C 1–4) as the reference group. Men and women were examined separately, and age-stratified analyses were performed.
Having an AUDIT-C score of 9–12 (indicating severe alcohol misuse) was associated with increased risk for trauma. Mean (SD) ages for men and women were 68.2 (11.5) and 57.2 (15.8), respectively. Age-stratified analyses showed that, for men ≤50 years, those with AUDIT-C scores ≥9 had an increased risk for trauma compared with those with AUDIT-C scores in the 1–4 range (adjusted prevalence, 25.7% versus 20.8%, respectively; OR = 1.24; 95% confidence interval [CI], 1.03–1.50). For men ≥65 years with average comorbidity and education, those with AUDIT-C scores of 5–8 (adjusted prevalence, 7.9% versus 7.4%; OR = 1.16; 95% CI, 1.02–1.31) and 9–12 (adjusted prevalence 11.1% versus 7.4%; OR = 1.68; 95% CI, 1.30–2.17) were at significantly increased risk for trauma compared with men ≥65 years in the reference group. Higher AUDIT-C scores were not associated with increased risk of trauma among women.
Men with severe alcohol misuse (AUDIT-C 9–12) demonstrate an increased risk of trauma. Men ≥65 showed an increased risk for trauma at all levels of alcohol misuse (AUDIT-C 5–8 and 9–12). These findings may be used as part of an evidence-based brief intervention for alcohol use disorders. More research is needed to understand the relationship between AUDIT-C scores and risk of trauma in women.
PMCID: PMC3414833  PMID: 22966411
Alcohol; Trauma; Fracture; AUDIT-C; Age; Gender; Screening; Women

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