Two waves of surveys were administered at varying times by each cohort between May 11th, 2020 and February 15th 2021. Given our objective to explore associations of alcohol and other drug use, we conducted a cross-sectional analysis of survey respondents who had complete information on alcohol use and the covariates of interest. If people responded to more than one wave of the survey, we used their first survey. We explored incorporating alcohol consumption prior to the start of the COVID-19 pandemic but 75% of the respondents were missing this information which limited this analysis. The primary outcome was alcohol use, categorized into three groups based on participant responses to the United States Alcohol Use Disorders Identification Test – Consumption questions , modified to ask about drinking in the past 30 days rather than past year . We denote the three groups as; no alcohol use , low-risk alcohol use, and hazardous alcohol use based on terminology best practices .The third question asks about heavy episodic drinking . Heavy episodic drinking was defined as reporting drinking ≥ 4 drinks for women or ≥ 5 drinks for men in a single occasion , 2016. Hazardous alcohol use was defined as averaging ≥ 7 drinks per week for females and males ≥ 65 years of age, ≥ 14 drinks per week for males < 65 years of age or reporting heavy episodic drinking on any occasion in the past month. Low risk alcohol use was defined as reporting any alcohol use below the thresholds for hazardous use. No alcohol use was defined as reporting no alcohol use in the past 30 days. Demographic covariates included age, sex assigned at birth , and self-reported race/ethnicity. We also included two indicators of socio-economic status: employment status and current food insecurity. Respondents were classified as employed if they endorsed being employed full time,roll bench employed but with a reduction in hours, furloughed, or working “without formal employment” . Current food insecurity was defined as endorsing either not having enough money for food, or rationing food.
Mental health variables considered were anxiety measured on the Generalized Anxiety Disorder-7 categorized as none-low anxiety , resilience as classified by the Brief Resiliency Scale categorized as low , normal , or high resiliency , self-reported disruptions to mental health care during the pandemic, and level of worry about the pandemic. Patients reported their level of worry about COVID-19 on a scale of 1–10, and patients who reported a level of ≥ 5 were classified as having substantial worry. HIV status was self-reported at the time of the survey. Current drug use was ascertained using the second question of the Alcohol, Smoking and Substance Involvement Screening Test modified to ask about the past-month frequency of use . ASSIST provides 5 levels of frequency of use and participants werecategorized as self-reported past month use for each of the following substances: tobacco, stimulant , non-prescribed opioid , and cannabis. Participants also reported whether they were currently receiving any substance use disorder treatment . Participants who reported being in substance use disorder treatment also reported whether there had been any disruptions to their treatment which could include missed in-person or telemedicine visits with clinicians or disruption in medications. Overdose was defined as self-reporting an overdose event in the past 30 days at the time of the survey. Lastly, because of broad differences in the six cohorts’ geographic and social profiles due to different study goals, cohort was included as an adjustment variable, as was survey wave . We did not adjust for calendar month in which the survey was completed due to high collinearity with cohort. We determined the proportion of individuals who reported no alcohol use, low-risk use, and hazardous use in the past 30 days. We examined associations between the covariates listed above with low-risk alcohol use and with hazardous alcohol use using multi-nomial logistic regression, with no alcohol use as the reference category. Age was included as a linear covariate in the model. On visual inspection of the relationship of age and prevalence of hazardous or low-risk alcohol use relative to no alcohol use, the rate of prevalence decrease for each increasing year of age was different for those ages < 50 and ≥ 50.
We accounted for this by adding a knot at age 50 which allows for separate slopes to be calculated for ages < 50 and ≥ 50. We report the results of both crude and fully adjusted models . A post-hoc secondary analysis was conducted to measure the association between opioid and stimulant use patterns and alcohol use. A total of 2121 participants completed a survey. Of these, 14 participants were excluded due to missing alcohol use information on their survey. We excluded 123 participants that were missing information on any covariates of interest. Table 1 provides the study population characteristics. The median age of the study sample was 42 years, and a majority were male and non-Hispanic Black . Current employment was reported by 43% of participants and 28% reported some limitations to their access to food. At the time of the survey, 42% reported having HIV. Overall, 45% of the sample reported no alcohol use in the past 30 days, 33% reported low-risk alcohol use, and 22% reported hazardous alcohol use. Current tobacco use and cannabis use were relatively common and there was substantial use of stimulants and opioids as well. Of 351 participants who used either opioid or stimulants, 224 used stimulants only, 77 used opioids only, and 50 used both opioids and stimulants. Of the 17% of participants who were receiving substance use disorder treatment, 69% experienced disruptions to their treatment. Ten participants reported recent overdose. Table 2 shows the proportion of participants who reported current drug use and recent overdose by alcohol use category. Compared to participants with no alcohol use, participants with low-risk alcohol use had higher prevalence of stimulant use and cannabis use and similar levels of tobacco use , opioid use , and recent overdose . Among participants with hazardous alcohol use, there was a higher prevalence of tobacco , stimulant , opioid , cannabis use and overdose compared to participants with no alcohol use. Multinomial logistic regression estimates a ratio of prevalence ratios . In the crude analyses adjusted only for cohort, the prevalence of low-risk alcohol use relative to no alcohol use decreased with each year of age before the age of 50 and also after the age of 50 . The prevalence of low-risk alcohol use relative to no use was statistically higher among males and among employed participants , and lower among participants with HIV .
With respect to drug use, cannabis had the largest association with low-risk alcohol use relative to no alcohol use , but any drug use was associated with a higher prevalence of low-risk versus no use: tobacco , stimulants , and opioids . Participants receiving substance use treatment had a lower prevalence of low-risk alcohol use relative to no use . Among those in substance use treatment, there was a non-significant increase in the relative prevalence of low-risk alcohol use among those whose treatment was interrupted . Participants with recent overdose had a non-significant increased prevalence of low risk alcohol use relative to no use . Self reported race, food insecurity, and survey round were not significantly associated with the prevalence of low-risk relative to no alcohol use, nor were the mental health indicators of low-risk-to-severe anxiety, resilience, interruptions to mental healthcare, or worry about the pandemic. In the fully adjusted model , the prevalence of low-risk alcohol use relative to no use decreased with each year of age before 50 but not after 50 . The prevalence of low-risk alcohol use relative to no use remained higher among males and employed participants , and remained lower among participants with HIV . White participants had a lower prevalence of low-risk alcohol use relative to no use compared to non-Hispanic, Black participants. After adjustment, opioid use and tobacco use were no longer significantly associated with higher prevalence of low-risk alcohol use relative to no use ,drying rack cannabis but cannabis maintained the strongest association followed by stimulants . Receiving substance use treatment was still associated with a lower prevalence of low-risk alcohol use compared to no use . In our multi-cohort study of people with and at risk for HIV with high prevalence of drug use, we found that nearly a quarter of participants reported drinking above recommended levels set by NIAAA. As expected , drug use was relatively common and higher compared to the general population . However, the significant relationship between hazardous alcohol use and stimulant use is notable. Stimulant use in the last month was reported by 13% of all participants, while one-in-four participants with hazardous alcohol use reported stimulant use; when compared to people who did not report stimulant use, stimulant use was associated with a nearly 3-fold increase in prevalence of hazardous alcohol use compared to no use. Overdose deaths involving stimulants is rising and recognizing the strong relationship of hazardous alcohol use with stimulants should lead clinicians to screen for both alcohol and stimulant use when patients report using one those substances. Additional studies examining the temporal relationship of alcohol and stimulant use are needed to understand this relationship. Alcohol sales surged at the start of the COVID-19 pandemic with a 54% increase in sales in March 2020 . Multiple nationally representative surveys showed that alcohol spending and consumption increased . The prevalence of hazardous alcohol use in our study is comparable to U.S. general public which potentially suggests that, when considering alcohol use alone, these cohorts are similar to the broader community . However, we believe this finding should be a cause for specific concern for the End the HIV Epidemic plan . Alcohol use is associated with behaviors which increase the risk of HIV transmission, less adherence to anti-retroviral treatment, and lower retention of care among people with HIV which could hinder the national goal of stopping the HIV epidemic . At the same time that alcohol use is increasing, surveillance data shows that drug overdoses are now at the highest levels ever recorded . In both US and Canada, most overdose deaths involve heroin tainted by illicitly manufactured fentanyl and represent a continuation and worsening of the opioid overdose epidemic. However, stimulant use, including cocaine and methamphetamines, was rising prior to the COVID-19 pandemic, and stimulants are now involved in nearly half of overdose deaths .
In our study, stimulant use was strongly associated with both low-risk and hazardous alcohol use. Understanding the context and patterns of people’s use of alcohol and stimulants could inform harm reduction approaches as simulant use becomes more widespread. Other drug use including tobacco, cannabis, stimulants, and opioids was associated with increased prevalence of low-risk or hazardous alcohol use relative to no use. This result is consistent with previous studies demonstrating an association between hazardous alcohol use and other drug use . The drug most strongly associated with low-risk or hazardous alcohol use was cannabis, indicating the rarity of cannabis use in the absence of alcohol use. Opioid use alone was only weakly and not statistically significantly associated with hazardous alcohol use; the association between opioid use and stimulant use together and low-risk alcohol use was weaker and not statistically significant. People often mix opioids and stimulants, specifically cocaine, and combining both drugs could be a marker of more intense drug use and thus also more intense alcohol use. The co-use of opioids and alcohol raises the risk of overdose ; one-in-seven opioid overdose deaths involved alcohol . Given the association between these three substances in our study, further public health surveillance of hazardous alcohol use and its identification and treatment when caring for people who use opioids and stimulants could inform harm reduction approaches as simulant use becomes more widespread. For participants who had current substance use treatment and for those who have HIV, there was a lower prevalence of hazardous alcohol use. Given the cross-sectional nature of the study, we consider several potential explanations. For participants undergoing substance use treatment, they could be more motivated to not drink just as they are motivated to engage in substance use treatment .