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IIR 06-058 – HSR&D Study

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IIR 06-058
Primary Care Based Disease Management for Alcohol Dependence
David W. Oslin MD
Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
Philadelphia, PA
Funding Period: July 2007 - March 2011

BACKGROUND/RATIONALE:
Data suggest that primary care may be a key component in the identification of alcohol dependent patients, the delivery of initial interventions, and the success of addiction treatment. Yet most alcohol dependent individuals are not engaged in treatment despite screening efforts.

OBJECTIVE(S):
The primary aims of this proposal were to test the effectiveness of a primary care based Alcohol Care Management (ACM) program and to evaluate the barriers and facilitators to accessing and engaging individuals who are alcohol dependent into treatment. The ACM program uses a Behavioral Health Specialist to deliver care focused on the use of pharmacotherapy in combination with psychosocial support (Medication Management). The main hypothesis was that a significantly greater proportion of patients with alcohol dependence assigned to ACM would obtain improvement in drinking outcomes (reduction in rates of relapse across time) compared to usual care.

METHODS:
Primary care patients who scored >7 on the AUDIT-C and who were not engaged in specialty MH/SA care in the prior 12 months were identified and approached for research participation. Patients who consented completed an initial assessment including treatment barriers and attitudes about treatment, and a clinical assessment. Participants who consented to treatment (n=163) were randomly assigned to referral to existing alcohol specialty care (n=77) or to enrollment in ACM (n=86). Treatment was offered for up to 6 months in the ACM arm. Consenting patients, including those who refused treatment, were assessed for engagement, meeting of quality care indicators, and alcohol use at 3, 6, 9, and 12 months.

FINDINGS/RESULTS:
Our initial pass at secondary outcomes for drinking suggest heavy drinking days may be less in the primary care treatment compared to usual care. This is likely related to higher engagement rates. Abstinence also favors primary care but is not significant.

IMPACT:
Despite the availability of efficacious treatments, fewer than 20% of individuals with alcohol dependence are actively engaged in treatment. Screening was implemented within the VA system to identify patients with both abuse and dependence in order to increase access to specialty care. Data indicate that, among those individuals screened in primary care who have AUDIT-C scores of >7, only 29% are formally evaluated/referred. Of those assessed and referred to specialty care, only 60% attend an initial visit and only 33% meet the EPRP performance measure of 2 visits per month for 90 days.


Demonstration that ACM leads to improved access, engagement, and outcomes for alcohol dependent individuals would provide greater capacity to deliver a spectrum of care that includes brief interventions, ACM, outpatient specialty care, and residential care. Early results underscore access issues as important. Thus, ACM would be viewed as one component of a wider array of services than is currently available to alcohol dependent patients. ACM would be a model program for providing integrated care in primary care settings as required in the Uniform Services Handbook for Mental Health Services.

PUBLICATIONS:

Journal Articles

  1. Rotenberg JR, Leong SH, Maisto SA, McKay JR, Possemato K, Ingram E, Oslin DW. Post-intervention Durability of Alcohol Care Management: 1-Year Follow-up of a Randomized Controlled Trial. Journal of general internal medicine. 2018 Oct 1; 33(10):1626-1628.
  2. Moskal D, Maisto SA, Possemato K, Lynch KG, Oslin DW. Testing Mediators of Reduced Drinking for Veterans in Alcohol Care Management. Military medicine. 2018 Sep 1; 183(9-10):e594-e602.
  3. Possemato K, Funderburk J, Spinola S, Hutchison D, Maisto SA, Lantinga LJ, Oslin DW. Reliability and Validity of a Treatment Barriers Scale for Individuals With Alcohol Use Disorder. Substance use & misuse. 2016 Feb 18; 51(3):383-94.
Book Chapters

  1. Oslin DW. Addictions. In: Pacala JT, Sullivan GM, editors. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine (7th edition). New York: American Geriatrics Society; 2010. 298-303 p.
Conference Presentations

  1. Oslin DW. How the VA meets the mental health needs of elderly Veterans. Paper presented at: American Association for Geriatric Psychiatry Annual Meeting; 2012 Mar 18; Washington, DC.
  2. Arnold B, Rodrigues AE, Funderburk JS, Possemato K, Lantinga LJ, Maisto SA, Oslin DW. Does comorbidity predict treatment barriers in alcohol-dependent Veterans? Paper presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD.
  3. Oslin DW. Pain disability moderates depression monitoring outcomes for primary care Veterans newly prescribed an antidepressant. Poster session presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 28; Baltimore, MD.
  4. Oslin DW. Treatment barriers and preferences for alcohol dependent Veterans in primary care. Presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 28; Baltimore, MD.
  5. Oslin DW, Oslin DW. Psychiatric status and work performance in Veterans of Operations Enduring Freedom and Iraqi Freedom. Paper presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 27; Baltimore, MD.
  6. Oslin DW. Treatment barriers and preferences for alcohol dependent Veterans in primary care. Paper presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 29; Little Rock, AR.
  7. Oslin DW. Accessing and delivering substance use/abuse treatment in different settings: the VA perspective. Paper presented at: National Institute on Drug Abuse Annual Conference; 2008 Dec 1; Washington, DC.
  8. Oslin DW. Considering addictive disorders. Paper presented at: VA TIDES Depression Care Manager and Primary Care-Mental Health Integration Annual Conference; 2008 Nov 1; Pasadena, CA.


DRA: Substance Abuse and Addiction, Health Systems
DRE: Treatment - Observational, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Addictive Disorders, Alcohol, Behavior (patient)
MeSH Terms: none

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