According to the VHA Handbook on Uniform Mental Health Services (UMHS), availability and consideration of FDA approved pharmacotherapy for alcohol abuse and alcohol dependence (collectively termed alcohol use disorders or AUD) are consensus standards of high-quality care and mandated for all VHA facilities. Yet, even among AUD patients in VHA substance use disorder (SUD) specialty care, rates of AUD pharmacotherapy are low and highly variable (mean = 6%; range 0% to 20%).
The goal of this project is to understand the provider-, facility-, and system-level barriers and supports for AUD pharmacotherapy, especially within VHA SUD specialty care settings. This is a developmental evaluation guided by the PARIHS model, focusing on the assessment of evidence and context elements (i.e., pre-implementation research to be used in the design of future implementation studies).
Clinicians, managers, and pharmacists at VHA facilities with the 30 highest and 30 lowest rates of AUD pharmacotherapy were invited to participate in a survey and an interview about attitudes towards and decision-making regarding AUD pharmacotherapy. Participants were surveyed and interviewed regarding their knowledge of, attitudes toward, and decision making about pharmacotherapy for AUD, as well as perceived barriers and support to the implementation of pharmacotherapy for AUD. Data from the 2008 Drug and Alcohol Program Survey (DAPS) and semi-structured interviews of key informants from the programs complemented the survey data.
Fifty-nine participants from 19 of 30 high and 11 of 30 low adopting facilities completed the survey (overall facility-level response rate = 50%) and 23 participated in the interview (16 from high-prescribing stations). Survey data indicated that the top four barriers to increased consideration and use of AUD pharmacotherapy were generally consistent across high and low adopting facilities and included low patient demand, pharmacy or formulary restrictions, lack of skills or knowledge, and lack of confidence in effectiveness. Low patient demand was rated as the greatest barrier for oral naltrexone and disulfiram, whereas pharmacy or formulary restrictions were rated as the greatest barrier for acamprosate and injectable naltrexone. The three strategies rated across high and low adopting facilities as most likely to facilitate consideration and use of AUD pharmacotherapy were more education to prescribing providers about medications, more education to patients about existing medications, and increased involvement of physicians in alcoholism treatment. Interview data, analyzed with content analysis, were generally consistent with the survey data.
This research produced knowledge regarding the barriers and supports for availability and consideration of AUD pharmacotherapy, a standard of care that occurs with great variability across the VHA system. This knowledge has provided a foundation for our future plans to design, deploy, and evaluate targeted implementation efforts to increase the availability and consideration of AUD pharmacotherapy, consistent with the VHA UMHS and goals of the Substance Use Disorders- Quality Improvement Enhancement Research Initiative (SUD-QUERI). Specifically, we have submitted a concept letter to QUERI to evaluate the impact of a direct-to-patient educational intervention to increase the utilization of these medications in facilities with historically low use.
- Harris AH, Ellerbe L, Reeder RN, Bowe T, Gordon AJ, Hagedorn H, Oliva E, Lembke A, Kivlahan D, Trafton JA. Pharmacotherapy for alcohol dependence: perceived treatment barriers and action strategies among Veterans Health Administration service providers. Psychological Services. 2013 Nov 1; 10(4):410-9.
- Oliva EM, Maisel NC, Gordon AJ, Harris AH. Barriers to use of pharmacotherapy for addiction disorders and how to overcome them. Current psychiatry reports. 2011 Oct 1; 13(5):374-81.
- Harris AH. Pharmacotherapy for Alcohol Use Disorders in VA: Rates of Initiation, Adherence, and Barriers to Dissemination. Poster session presented at: VA Psychology Leadership Conference; 2011 May 20; San Antonio, TX.
- Harris AH, Kivlahan D, Hagedorn H, Reeder R, Ellerbe L. Barriers and supports for pharmacotherapy in alcohol use disorders in the Veterans Health Administration. Paper presented at: Addiction Health Services Research Conference; 2010 Oct 23; Lexington, KY.