Alcohol Misuse

Goal 1: Improve Detection and Management of Alcohol Misuse in Primary Care

Background

Alcohol misuse ranges from drinking above recommended limits without problems (risky drinking) to severe alcohol use disorders (alcohol dependence). Current research supports varying interventions for alcohol misuse depending on its severity and patients' readiness to change their drinking behavior. The majority of patients with alcohol misuse engages in risky drinking or has mild problems due to drinking without dependence, and these patients clearly benefit from brief alcohol counseling. Brief alcohol counseling may be delivered by non-specialists (e.g., primary care providers), and a meta-analysis by the former Research Coordinator of the SUD QUERI (e.g., Moyer et al., 2002) and a recent Cochrane review (Kaner et al., 2007), have concluded that brief alcohol counseling results in decreased drinking. Routine brief alcohol counseling with patients who screen positive for alcohol misuse is recommended in the VA/DOD Substance Use Disorders Guideline and by the U.S. Preventive Services Task Force (VA/DOD 1999; Whitlock, et al., 2004). In 2006 brief alcohol counseling was designated one of 10 top US prevention priorities based on the societal burden of alcohol misuse and its efficacy and cost-effectiveness (Maciosek et al., 2006). A recent report demonstrated the efficacy of brief alcohol counseling by telephone (Brown, 2007).

Routine alcohol screening to identify patients with alcohol misuse is recommended (as an antecedent to brief alcohol counseling), because many patients with alcohol misuse are not identified by primary care or mental health providers in the absence of routine screening. Although the VA has implemented routine alcohol screening, implementation of routine brief alcohol counseling has proven challenging, in part because there is no well-defined, efficient method for measuring performance of brief alcohol counseling. The importance of performance measurement in mental health was addressed in a recent major report of the Institute of Medicine, but the report did not address measurement of brief alcohol counseling.

Patients with severe alcohol dependence, serious mental illness, or medical contraindications to drinking usually have been omitted from trials of brief alcohol counseling because of expectations that these patients need specialized addictions treatment. Expert opinion and some research supports referral of these patients to specialty SUD care. For VA patients hospitalized with severe alcohol use disorders who are not willing or ready to engage in specialized addictions treatment, recent research supports repeated (e.g., monthly) patient-centered counseling interventions delivered post-discharge by nurses or other non-specialists. This practice is recommended by the VA/DOD Substance Use Disorders Guideline and referred to as "care management" (Willenbring, 2001) and NIAAA Clinicians Guide (revised 2007).

Pharmacologic management for alcohol dependence also has known efficacy. Although many studies have shown that both Naltrexone and Acamprosate are effective treatments for alcohol dependence, results from the multi-site COMBINE study revealed that for alcohol dependent patients seeking alcohol treatment Naltrexone with medical management had modest but significant advantages over other combinations, and a reanalysis of the originally negative VA trial of naltrexone suggested a benefit in VA patients as well (Gueorguieva, et al., 2007). Acamprosate and a state of the art behavioral intervention had no added efficacy compared to placebo and 9 sessions of medical management (Anton et al., 2006). However, no study has demonstrated the efficacy of treating alcohol dependent primary care patients with naltrexone, although there is now evidence that for patients who respond to naltrexone continuing naltrexone management in primary care is efficacious (O'Malley, et al., 2003). Further research is necessary and ongoing (Oslin et al., 2006) to determine best practices in this area.

Gaps in Current VA Practice

Research indicates that most patients who screen positive for alcohol misuse are not counseled by primary care providers. Important barriers to brief alcohol counseling have been: lack of standardized methods of identification of the eligible population (patients with alcohol misuse), the perception that alcohol misuse counseling is not central to the medical agenda, absence of a VHA national performance measure for brief alcohol counseling, multiple competing priorities during primary care and mental health visits, lack of necessary skills among some providers, and lack of consensus about methods for monitoring process or health outcomes among patients with alcohol misuse.

Implementation Approach and Impact to Date

Major implementation foci to date have been helping the VHA achieve readiness for system-wide brief alcohol counseling and population based management for alcohol dependence. For example, activities have included education of quality managers via national videoconference presentations [QMICs], collaboration on the development of national performance measures for first screening and recently brief alcohol counseling, bringing a Clinical Applications Coordinator (CAC) onto our team so we could develop and test CPRS tools consistent with those performance measures, and development of a website for disseminating information regarding alcohol screening and brief alcohol counseling. This approach has often allowed us to use diffusion, rather than dissemination, for key steps in implementation (e.g., national implementation of alcohol misuse screening), which, thus far, has resulted in rapid spread, as well as sustainability (Bradley et al., 2006; Bradley et al., 2007).

The Alcohol Misuse Work Group meets monthly by teleconference to discuss specific issues regarding implementation. This year, discussions with the AMWG were used to share projects that QUERI investigators were working on, and to evaluate possible collaborations for the future.

Clinical Implementation Accomplishments in 2007

• Improved efficiency and standardization of alcohol screening. Drs. Bradley and Kivlahan, and Ms. Achtmeyer, collaborated with leaders in OQP and PCS to improve screening procedures for FY08:
  • AUDIT-C skip pattern: Nondrinkers (45% of VA outpatients) are now required to be asked only the first of the three AUDIT-C questions using a validated skip pattern integrated into CPRS.
  • Improved standardization: The screening clinical reminder now prompts clinicians to ask screening questions verbatim, in a private setting, and non-judgmentally.
  • Testing new clinical software: Ms. Achtmeyer ARNP was central to the careful testing of new national CPRS technology to support mental health screening.
• New transformational performance measure (PM) for brief alcohol counseling:
  • Higher AUDIT-C threshold (>= 5): We recommended and clinical leaders accepted a higher cut-point for the PM, to decrease false positive AUDIT-Cs.
  • Transformational performance measure: A national evidence-based PM for brief alcohol counseling based on EPRP was proposed and largely implemented.
• CPRS clinical reminder for brief alcohol counseling:
  • Revised clinical reminder: In collaboration with Dr. Volpp, we piloted and conducted a formative evaluation of a clinical reminder, leading to revisions.
  • Disseminated CPRS clinical reminder 9/07: The reminder was approved and made available nationally by Primary Care leaders, Drs. Post and Mayo-Smith.
• EPRP measures for brief alcohol counseling:
  • Evaluated pilot data on EPRP measures of brief alcohol counseling revealing limitations in data elements and presented findings to VACO.
  • Recommended revisions to EPRP data fields were accepted for FY07 Qtrs 2-3 and FY08 Qtr 1, based on preliminary analyses.
• Successful collaboration with Pharmacy Benefits Management (PBM):
  • We recommended a "do not drink alcohol" label for warfarin and collaborated with PBM in a successful request for a label change from a VA contractor.
• Participation in national efforts to integrate mental health care in primary care:
  • Participated in mental health-primary care integration leadership committees and national training conference for primary care providers in Denver.

During national conference calls in September 2007, Dr. Mayo-Smith, Chief Consultant for Primary Care, recognized Drs. Bradley and Kivlahan for "for years of patient, ground-breaking research and innovation on alcohol screening and brief intervention."

Progress and Accomplishments

• Impacts, Contributions and Products
• Publications and Presentations
• Active and Completed Projects
• Planned Projects
• Implementation Pipeline (PDF)

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