Access to health care and heavy drinking in patients with diabetes or hypertension: implications for alcohol interventions

Community characteristics and substance-free activity and service access predict membership in alcohol use disorder risk profiles

OBJECTIVE

Community characteristics (e.g., alcohol access, poverty) are associated with alcohol use disorder (AUD) at the population level, and person-level AUD severity indicators (e.g., drinking practices, problems) predict heterogeneity in individual AUD risk profiles and recovery outcomes. Guided by behavioral economic theory, this study investigated whether residing in relatively enriched communities with substance-free reward sources, greater health/behavioral health care access, lower alcohol access, and less poverty were associated with less risky individual AUD risk profiles.

METHOD

This secondary analysis combined an integrated data set of individual natural recovery attempts with zip code community characteristics obtained from public data sources. Four AUD latent risk profiles, previously derived from individual problem severity indicators that predicted 1-year recovery outcomes, were predicted by zip code-level substance-free reward sources, alcohol access, health/behavioral health care access, and poverty surrounding AUD recovery (N = 528).

RESULTS

As hypothesized, multinomial regression analyses indicated that greater community access to substance-free reward sources (educational services, religious organizations, sports/fitness/recreation programs, fresh food) and lower community poverty were associated with lower AUD risk profiles compared with higher AUD risk profiles. This pattern was most pronounced in comparisons between a global lower risk profile and a higher risk profile characterized by high alcohol dependence and alcohol-related psychosocial problems. Alcohol access and health care access did not differentiate profile membership.

CONCLUSIONS

Results suggest that community characteristics contribute to heterogeneity in individual drinking problem development, and community enrichment may offer a promising approach to AUD prevention and promotion of positive recovery outcomes. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Screening for Unhealthy Alcohol Use Among Patients With Multiple Chronic Conditions in Primary Care

Introduction

Unhealthy alcohol use increases the risk for and exacerbation of chronic health conditions. As such, screening, prevention, and management of unhealthy alcohol use is especially critical to improving health outcomes for patients with multiple chronic health conditions. It is unclear to what extent multiple chronic condition status is a barrier to screening for unhealthy alcohol use in the primary care setting. The authors hypothesized that patients with multiple chronic conditions would be at lower odds of being screened for unhealthy alcohol use than patients without multiple chronic conditions.

Methods

The authors performed a secondary analysis of electronic health record data for patients from 67 primary care practices in Virginia (2020-2023). Using the Center for Medicare and Medicaid Services' chronic disease framework, they classified patients by multiple chronic condition status: no multiple chronic conditions, physical multiple chronic conditions, mental health multiple chronic conditions, and physical and mental health multiple chronic conditions. They used multiple logistic regressions with an added practice-level random effect to analyze the relationship between multiple chronic condition status and the odds of receiving an alcohol-related assessment, of being screened for unhealthy alcohol use with a U.S. Preventive Services Task Force-recommended instrument, and of screening positive for unhealthy alcohol use within the past 2 years.

Results

Within a final cohort of n=11,789, a total of 6,796 patients (58%) had multiple chronic conditions (29% physical multiple chronic conditions, 4% mental health multiple chronic conditions, and 25% physical and mental health multiple chronic conditions). In all, 69% of patients were screened for unhealthy alcohol use, whereas 16% were screened with a U.S. Preventive Services Task Force-recommended instrument, and 7% screened positive for unhealthy alcohol use. Patients with physical and mental health multiple chronic conditions had 0.9 times lower odds of receiving any screening for unhealthy alcohol use than those with no multiple chronic conditions (95% CI=0.8, 1.0; p=0.0240), whereas patients with only physical multiple chronic conditions or only mental health multiple chronic conditions had similar odds. There was no difference in the odds of being screened with a U.S. Preventive Services Task Force-recommended instrument on the basis of multiple chronic condition status. Patients with mental health multiple chronic conditions and physical and mental health multiple chronic conditions had 1.8 and 1.5 times greater odds of screening positive for unhealthy alcohol use, respectively (95% CI=1.3, 2.7; p=0.0014 and 95% CI=1.2, 1.8; p=0.0003).

Conclusions

Although patients with chronic mental health conditions were more likely to screen positive for unhealthy alcohol use than patients without multiple chronic conditions, Virginia primary care patients with physical and mental health multiple chronic conditions were less likely to receive an alcohol-related assessment during the past 2 years. Given the overall modest rate of screening with a U.S. Preventive Services Task Force-recommended instrument, further efforts are needed to create the conditions for high-quality alcohol-related preventive service delivery in primary care, particularly for patients with high complexity and/or mental health conditions.

At-Risk Drinking in US Adults with Health Conditions: Differences by Gender, Race, and Ethnicity in the National Survey of Drug Use and Health, 2015-2019

Few studies in the US address alcohol consumption patterns in adults with chronic health conditions, and little is known about race and ethnicity differences. This study examined at-risk drinking prevalence rates among US adults with hypertension, diabetes, heart condition or cancer and assessed differences by gender and, among adults aged 50 and older, by race and ethnicity. We used data from the 2015-2019 National Survey on Drug Use and Health (N = 209,183) to estimate (1) prevalence rates and (2) multivariable logistic regression models predicting odds of at-risk drinking among adults with hypertension, diabetes, heart condition, or cancer, compared to adults with none of these conditions. To examine subgroup differences, analyses were stratified by gender (ages 18-49 and ages 50 +) and by gender and race and ethnicity for adults ages 50 + . Results showed that all adults with diabetes and women ages 50 + with heart conditions in the full sample had lower odds of at-risk drinking relative to their counterparts without any of the four conditions. Men ages 50 + with hypertension had greater odds. In race and ethnicity assessments among adults ages 50 + , only non-Hispanic White (NHW) men and women with diabetes and heart conditions had lower odds, and NHW men and women and Hispanic men with hypertension had greater odds of at-risk drinking. There were differential associations of at-risk drinking with demographic and lifestyle indicators across race and ethnicity groups. These findings underscore tailored efforts in community and clinical settings to reduce at-risk drinking in subgroups with health condition diagnoses.

Influence of Sex and Sex-Based Disparities on Prevalent Tuberculosis, Vietnam, 2017-2018

To assess sex disparities in tuberculosis in Vietnam, we conducted a nested, case-control study based on a 2017 tuberculosis prevalence survey. We defined the case group as all survey participants with laboratory-confirmed tuberculosis and the control group as a randomly selected group of participants with no tuberculosis. We used structural equation modeling to describe pathways from sex to tuberculosis according to an a priori conceptual framework. Our analysis included 1,319 participants, of whom 250 were case-patients. We found that sex was directly associated with tuberculosis prevalence (adjusted odds ratio for men compared with women 3.0 [95% CI 1.7-5.0]) and indirectly associated through other domains. The strong sex difference in tuberculosis prevalence is explained by a complex interplay of factors relating to behavioral and environmental risks, access to healthcare, and clinical manifestations. However, after controlling for all those factors, a direct sex effect remains that might be caused by biological factors.

Association of short-term changes in drinking after onset of a serious health condition and long-term heavy drinking

BACKGROUND

Literature on changes in drinking following diagnosis of chronic health conditions is limited, especially differential response to specific conditions or across demographic subgroups. Methods Data were analyzed from the 2020 National Alcohol Survey of the U.S. adult population (n = 9968). Predictors of change in drinking following first diagnosis of hypertension, heart disease, diabetes, and cancer, and how the short-term post-disease change in drinking was associated with a change in long-term heavy (5 +) drinking from the decade before diagnosis to the decade following diagnosis were analyzed. Results The majority of respondents reported no change in drinking after diagnosis. Men were more likely than women to reduce drinking after hypertension (OR=1.47) but less likely to quit after heart disease (OR=0.46). Black and Hispanic/Latinx drinkers were more likely than white or other drinkers to reduce (OR=2.68, 2.35, respectively) or quit (OR=2.69, 2.34) after hypertension, and more likely to quit after diabetes (OR=3.44, 2.74) and cancer (OR=5.00, 5.27). Black drinkers were more likely to quit after heart disease (OR=3.26). Heavier drinkers were more likely to reduce or quit drinking than lighter drinkers. For all disease types, those who quit drinking after disease onset were less likely to report heavy drinking in the following decade. Conclusions Just cutting down had little effect on subsequent long-term heavy drinking compared to quitting. These data are important for informing efforts aimed at harm reduction in patients diagnosed with a chronic health condition and suggest specific demographic subgroups.

Binge Drinking among Economically Disadvantaged African American Older Adults with Diabetes

Purpose. This study investigated the effect of demographic, socioeconomic, and psychological factors as well as the role of health determinants on alcohol consumption and binge drinking among economically disadvantaged African American older adults with type 2 diabetes mellites (T2DM). Methods. This survey recruited 231 African Americans who were older adults (age 65+ years) and had T2DM. Participants were selected from economically disadvantaged areas of South Los Angeles. A structured face-to-face interview was conducted to collect data on demographic factors, objective and subjective socioeconomic status (SES) including education and financial difficulty, living arrangement, marital status, health, and drinking behaviors (drinking and binge drinking). Results. Age, gender, living alone, pain, comorbid conditions, and smoking were associated with drinking/binge drinking. Male gender, pain, and being a smoker were associated with higher odds of drinking/binge drinking, while individuals with more comorbid medical conditions had lower odds of binge drinking. Conclusion. In economically constrained urban environments, gender, pain, and smoking but not age, SES, depression, and health may predict binge drinking for African American older adults with T2DM. African Americans older adult men with T2DM with comorbid pain should be screened for binge drinking.

Alcohol brief intervention in primary care: Blood pressure outcomes in hypertensive patients

BACKGROUND

In clinical trials alcohol brief intervention (BI) in adult primary care has been efficacious in reducing alcohol consumption, but we know little about its impact on health outcomes. Hypertension is a prevalent and costly chronic condition in the U.S. and worldwide, and alcohol use is a modifiable hypertension risk factor.

OBJECTIVE

To evaluate the effect of receiving BI for unhealthy drinking on blood pressure (BP) control among adult hypertensive patients by analyzing secondary data from a clustered, randomized controlled trial on alcohol screening, brief intervention and referral to treatment (SBIRT) implementation by primary care physicians (PCP intervention arm) and non-physician providers and medical assistants (NPP&MA intervention arm) in a large, integrated health care delivery system.

DESIGN

Observational, prospective cohort study.

SUBJECTS

3811 adult hypertensive primary care patients screening positive for past-year heavy drinking at baseline, of which 1422 (37%) had an electronic health record BP measure at baseline and 18-month follow-up.

MAIN OUTCOME MEASURES

Change in BP and controlled BP (systolic/diastolic BP <140/90mmHg).

RESULTS

Overall no significant associations were found between alcohol BI and BP change at 18-month follow-up when analyzing the combined sample of subjects in both intervention arms. However, moderation analyses found that receiving BI for positive past-year unhealthy drinking was positively associated with better BP control at 18months in the PCP intervention arm, and for those with lower heavy drinking frequency and poor BP control at the index screening.

CONCLUSIONS

Our findings suggest that hypertensive patients may benefit from receiving physician brief intervention for unhealthy alcohol use in primary care. Findings also highlight potential population-level benefits of alcohol BI if widely applied, suggesting a need for the development of innovative strategies to facilitate SBIRT delivery in primary care settings.

Changes in heavy drinking following onset of health problems in a U.S. general population sample

Heavy episodic drinking is a well-established risk factor for heart disease, diabetes, certain cancers, stroke, hypertension and injuries, however, little is known about whether health problems precipitate changes in subsequent drinking patterns. Retrospective cohort analyses of heavy drinking by decade were conducted using data from the 2010 U.S. National Alcohol Survey (n=5240). Generalized estimating equations models were used to predict any, monthly, and weekly heavy (5+) drinking occasions across decades of life following a diagnosis of hypertension, heart problems, diabetes, stroke, cancer, or serious injury. Experiencing heart problems was associated with higher odds of reduced weekly heavy drinking (adjusted odds ratio (ORadj)=3.5; 95% confidence interval (CI); 1.7-7.4). The onset of diabetes was also associated with higher odds of reducing any heavy drinking over the decade (ORadj=1.7; 95% CI; 1.1-2.6). Cancer survivors were less likely to report no heavy drinking (ORadj=0.5; 95% CI; 0.3-0.8) or no weekly heavy drinking (ORadj=0.3; 95% CI; 0.2-0.7). Hypertension, stroke and injury were not found to have any significant associations. Reduced heavy drinking was more likely to be reported by Black drinkers following heart problems and Whites following a diabetes diagnosis. Increased heavy drinking following a cancer diagnosis was significant among women and Whites. Future studies on alcohol's heath and mortality risks should take into consideration effects of health problems on drinking patterns. Additionally, study results support increased prevention efforts targeting heavy drinking among cancer survivors, especially White women, and individuals with or being treated for hypertension.

Screening and brief intervention for unhealthy substance use in patients with chronic medical conditions: a systematic review

AIMS AND OBJECTIVES

This systematic review describes studies evaluating screening tools and brief interventions for addressing unhealthy substance use in primary care patients with hypertension, diabetes or depression.

BACKGROUND

Primary care is the main entry point to the health care system for most patients with comorbid unhealthy substance use and chronic medical conditions. Although of great public health importance, systematic reviews of screening tools and brief interventions for unhealthy substance use in this population that are also feasible for use in primary care have not been conducted.

DESIGN

Systematic review.

METHODS

We systematically review the research literature on evidence-based tools for screening for unhealthy substance use in primary care patients with depression, diabetes and hypertension, and utilising brief interventions with this population.

RESULTS

Despite recommendations to screen for and intervene with unhealthy substance use in primary care patients with chronic medical conditions, the review found little indication of routine use of these practices. Limited evidence suggested the Alcohol Use Disorders Identification Test and Alcohol Use Disorders Identification Test-C screeners had adequate psychometric characteristics in patients with the selected chronic medical conditions. Screening scores indicating more severe alcohol use were associated with health-risk behaviours and poorer health outcomes, adding to the potential usefulness of screening for unhealthy alcohol use in this population.

CONCLUSIONS

Studies support brief interventions' effectiveness with patients treated for hypertension or depression who hazardously use alcohol or cannabis, for both substance use and chronic medical condition outcomes.

RELEVANCE TO CLINICAL PRACTICE

Although small, the international evidence base suggests that screening with the Alcohol Use Disorders Identification Test or Alcohol Use Disorders Identification Test-C and brief interventions for primary care patients with chronic medical conditions, delivered by nurses or other providers, are effective for identifying unhealthy substance use and associated with healthy behaviours and improved outcomes. Lacking are studies screening for illicit drug use, and using single-item screening tools, which could be especially helpful for frontline primary care providers including nurses.

Intervention to reduce excessive alcohol consumption and improve comorbidity outcomes in hypertensive or depressed primary care patients: two parallel cluster randomized feasibility trials

BACKGROUND

Many primary care patients with raised blood pressure or depression drink potentially hazardous levels of alcohol. Brief interventions (BI) to reduce alcohol consumption may improve comorbid conditions and reduce the risk of future alcohol problems. However, research has not established their effectiveness in this patient population. This study aimed to establish the feasibility of definitive trials of BI to reduce excessive drinking in primary care patients with hypertension or mild to moderate depression.

METHODS

Thirteen general practices in North East England were randomized to the intervention or control arm of one of two parallel pilot trials. Adult patients drinking excessively and diagnosed with hypertension or mild-to-moderate depression received the Alcohol Use Disorders Identification Test (AUDIT) by postal survey. Consenting respondents scoring more than 7 on AUDIT (score range 0 to 40) received brief alcohol consumption advice plus an information leaflet (intervention) or an information leaflet alone (control) with follow-up at six months. Measurements included the numbers of patients eligible, recruited, and retained, and the AUDIT score and systolic/diastolic blood pressure of each patient or the nine-item Patient Health Questionnaire (PHQ-9) score. Acceptability was assessed via practitioner feedback and patient willingness to be screened, recruited, and retained at follow-up.

RESULTS

In the hypertension trial, 1709 of 33,813 adult patients (5.1%) were eligible and were surveyed. Among the eligible patients, 468 (27.4%) returned questionnaires; 166 (9.6% of those surveyed) screened positively on AUDIT and 83 (4.8% of those surveyed) were recruited (50.0% of positive screens). Sixty-seven cases (80.7% of recruited patients) completed follow-up at six months. In the depression trial, 1,044 of 73,146 adult patients (1.4%) were eligible and surveyed. Among these eligible patients, 215 (20.6%) responded; 104 (10.0% of those surveyed) screened positively on AUDIT and 29 (2.8% of those surveyed) were recruited (27.9% of positive screens). Nineteen cases (65.5% of recruited patients) completed follow-up at six months.

CONCLUSIONS

Recruitment and retention rates were higher in the hypertension trial than in the depression trial. A full brief intervention trial appears feasible for primary care patients with hypertension who drink excessively. High AUDIT scores in the depression trial suggest the importance of alcohol intervention in this group. However, future work may require alternative screening and measurement procedures.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN89156543; registered 21 October 2013.

Intercepting binge drinkers in medical settings: a view from California

The argument for universal alcohol screening in primary care is based on the assumption that most heavy drinkers routinely visit a doctor. This study examines whether drinking status is associated with higher or lower odds of visiting a doctor in the past year among California adults. As a point of comparison, the study also examines whether drinking status is associated with the odds of visiting an emergency room. Data came from the 2007 California Health Interview Survey. Multivariate logistic regression was used to examine the odds of visiting a doctor and an emergency room for abstainers, moderate drinkers, monthly binge drinkers, and weekly binge drinkers. After controlling for demographics, health coverage, and health status, binge drinkers had the same odds of visiting a doctor and the emergency room as moderate drinkers. Among binge drinkers, female gender, health coverage, and high blood pressure were associated with visiting a primary care doctor.