Screening and Brief Intervention for Alcohol Misuse in Primary Care: What Comes After the Screening Validation Studies and rct’s

• Screening and Brief Intervention for Alcohol Misuse in Primary Care:

• What Comes After the Screening Validation Studies and RCT’s

• CJ 556; 10/17/07

VA Motto: Lincoln’s 2nd Inaugural March 4, 1865

• “With malice toward none, with charity for all, with firmness in the right

• as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds,

• to care for him [sic] who shall have borne the battle and for his [sic] widow, and his [sic] orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.”

Veterans Health Administration

• - US largest integrated healthcare system

• - >5M veterans served in FY07

• - 157 medical centers

• - 721 community-based outpatient clinics

• - 21 regions

Infrastructure Advantages of VA

• National systems for administrative data

• Integrated electronic health record

• VA Office of Quality and Performance

• Incentivized performance monitoring
• Evidence-based treatment guidelines

• VA Health Services Research

• QUERI

QUERI Steps

• Select patient populations

• Identify E-B Guidelines/Recommendations

• Assess Performance Gaps

• Design/Implement Improvement Programs

• Evaluate impact on clinical outcomes

• Evaluate impact on health-related quality of life

Unique patients with SUD seen in VA 2002-2006

Perceived Need for Treatment of SUD: NSDUH 2006

Where Past Year Substance Use Treatment Was Received: 2006

Goals of SUD QUERI

• Improve detection and mgmt of alcohol misuse in primary care

• Improve retention of patients in continuing specialty care for SUD

• Implement effective smoking cessation treatment

• Improve detection and mgmt of patients with SUDs and SUD-related co-occurring disorders seen in primary care and other medical settings

• infectious disease (i.e., HIV, Hepatitis C)
• psychiatric co-morbidity

The Spectrum of Alcohol Use

What is Alcohol Dependence?

• 3 or more of these criteria in

• a 12-month period:

• 1. Tolerance
• 2. Withdrawal
• 3. More or longer consumption than intended
• 4. Cannot cut down or control alcohol use
• 5. A great deal of time getting, using, recovering
• 6. Activities given up or reduced
• 7. Use despite knowledge of health problem

Characteristics of 5 empirically-derived AD subtypes in the U.S. population (Moss et al. in press, Drug & Alc Dep)

What is Alcohol Misuse?

• Drinking above NIAAA recommended limits

• OR

• Diagnosis of abuse or dependence

• Together referred to as “alcohol misuse”

NIAAA recommended limits (US standard drink ~ 14 g alcohol)

• Men > 14 drinks/week or
• > 4 drinks/occasion
• Women > 7 drinks/week or
• > 3 drinks/occasion

How to Detect Alcohol Misuse?

• Biomarkers

• Self-report

New Biomarkers of Excess Alcohol?

• Carbohydrate-Deficient Transferrin (CDT)

• Ethylglucuronide (EtG)

• Transdermal devices

• Composite index from blood serum panel

• Hemoglobin Associated Acetaldehyde

• Fatty Acid Ethyl Esters (in hair)

Limitations of biological assays

• Cost and logistics

• Invasiveness

• Lack of sensitivity - timing

Self-Report Alcohol Misuse Screens

• CAGE (4 items)

• MAST (10-25 items)

• Michigan Alcoholism Screening Test

• AUDIT (10 items)

• Alcohol Use Disorders Identification Test

The CAGE Questions

• Have you ever felt you should Cut down on your drinking?

• Have people Annoyed you by criticizing your drinking?

• Have you ever felt bad or Guilty about your drinking?

• Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?

Alcohol Misuse Screening

AUDIT-C

Do Patients Accurately Report Drinking?

Screening for Hazardous Drinking or Alcohol Abuse or Dependence

AUDIT-C Score Reflects Risk

AUDIT-C Summary

• Score reflects severity and readiness to change

• Score may not accurately measure alcohol exposure (marker vs. measure)

• Can be used to risk-stratify for:

• Brief alcohol counseling
• Specialty care referral

Why Screen for Alcohol Misuse?

• Risk for adverse health outcomes (multiple studies; meta-analyses)

• Indication for brief alcohol counseling (BAC) that reduces alcohol consumption

• 2006 National Commission on Prevention Priorities identified BAC among top 10 prevention activities

Risk for adverse health outcomes

• Chronic heavy alcohol use

• Liver disease 2 drinks/day (m)

• Hypertension 3 drinks/day (m/w)

• Stroke 4 drinks/day (m/w)

• Mortality 4 drinks/day (m)

• Episodic heavy drinking

• Injury 5 drinks/occasion (m)

• STDs 4 drinks/occasion (w)

Why Screen for Alcohol Misuse?

• Risk for adverse health outcomes (multiple studies; meta-analyses)

• Indication for brief alcohol counseling (BAC) that reduces drinking risk

• 2006 National Commission on Prevention Priorities identified BAC among top 10 prevention activities

Authors' conclusions

• 28 controlled trials from various countries

• general practice (23 trials) or an emergency setting (5 trials).

• At trial entry, participants drank an average of 320 grams/week

• over 30 standard European drinks

• N> 7000 randomized to receive a brief intervention (BI) or a control intervention, including assessment only.

• At one year's follow up (17 trials), people who had received the BI drank less alcohol (mean difference of 41 grams).

• For men, the benefit of brief intervention was a reduction of 57 grams/week (range 25 to 89 grams).

• The benefit was not clear for women.

• Longer duration of counseling probably has little additional effect.

Why Screen for Alcohol Misuse?

• Risk for adverse health outcomes (multiple studies; meta-analyses)

• Indication for brief alcohol counseling (BAC) that reduces drinking risk

• 2006 National Commission on Prevention Priorities identified BAC among top 10 prevention activities

Priorities among Clinical Prevention Services (Maciosek et al, Am J Prev Med 2006)

• Service

• Aspirin chemoprophylaxis

• Childhood immunization series

• Tobacco screening and Brief Int.

• Colorectal concern screening

• Hypertension screening

• Influenza immunization

• Pneumocacal immunization

• Alcohol misuse Screening & Brief Intervention (SBI)

• Vision screening

• Cervical cancer screening

• Cholesterol screening

• Breast cancer screening

Benefits of Brief Alcohol Counseling

• 2007 Cochrane review and 9 other meta-analyses have demonstrated efficacy
• especially in men
• One of the top 10 US prevention priorities
• US: NNT 7-9 to move one patient from risky to non-risky drinking
• After 4 years, for every $1.00 spent on brief alcohol counseling, $4.30 saved on inpatient and emergency care

Helping Patients Who Drink Too Much: 5 A’s

• ASK about alcohol use

• ASSESS severity and readiness to change

• ADVISE cutting down or abstinence, and assist in goal setting

• ASSIST with further treatment when necessary

• ARRANGE follow-up to monitor progress

Express Empathy

• Express Empathy

• Develop Discrepancy

• Avoid Argumentation

• Roll with Resistance

• Support Self-Efficacy

PRINCIPLES OF MOTIVATIONAL INTERVIEWING

• Respect client autonomy, culture and choices.

• Acknowledge client as the active decision maker.

• Negotiate an agenda for change.

• Offer information in a neutral, non-personal manner.

• Ask open-ended questions.

• Practice reflective listening to encourage patients to talk about their drinking and the barriers to change.

• Accept resistance as a normal response.

• Avoid confrontation, labeling, stereotyping and forcing patients to accept a label or diagnosis.

Demystifying Motivational Interviewing for SUD

• “So this weekend I went into a store to buy some paint…The fellow at the counter…saw ‘CASAA’ on my shirt and asked what it is. I told him it’s an addiction treatment research center…he said, ‘I help people with that problem sometimes.’

• “Really? What do you do?”

• Bill Miller e-mail to MI Network of Trainers 3/29/05

Demystifying Motivational Interviewing for SUD

• “I just talk to them… I just do volunteer counseling. I help them see that they have a choice. We lay out the two sides – what happens if they continue on as they are, and what else they could do. And then I ask them which way they want to go. I don’t tell them what to do. It has to come from them. That’s what I do, and it just seems to help.”

• He had a 6th grade education

• Bill Miller e-mail to MI Network of Trainers 3/29/05

Promoting Action on Research Implementation in Health Services (PARIHS)

2 “Simple” Principles of Facilitation

• Feedback on local performance

• carefully defined
• accurately measured
• ongoing

• Accessible supervision or “coaching” from someone with more expertise about improvement

How to Measure Performance for Brief Alcohol Counseling ?

• No established performance measures

• No health care system has implemented brief alcohol counseling effectively

• VA is leader in routine alcohol screening

• WHO study to implement brief alcohol counseling found rates so low, 10% considered “excellent”

Data Sources for BAC Performance Measure: Limits and Feasibility

Self-reported Alcohol-related Advice If Screen+ for Alcohol Misuse

Developing a Brief Alcohol Counseling Performance Measure

• Evidence is strongest in non-dependent alcohol misuse, but recommended for all alcohol misuse – need to risk-stratify

• Key components of BAC:

• Advice: abstain or decrease drinking below limits
• Feedback linking drinking to health

• Completed specialty referral also acceptable follow-up of screening results

A Measure of Brief Alcohol Counseling Based on Medical Record Review

Scores of 5-7 (moderate risk)

• Most patients NOT alcohol dependent
• However, history of alcohol treatment increases risk

AUDIT-C Scores 8-12 (severe risk)

• Higher risk of dependence

• Increased risk of GI hospitalizations* mortality** and other co-morbidity

Alcohol Counseling Clinical Reminder

Summary

• Implemented screening for alcohol misuse

• Need appropriate follow-up

• Brief alcohol counseling or completed referral
• Higher than other health care systems, but much room for improvement
• Developed new performance measure

• Clinical reminder improves documented BAC

• Increased documented counseling: 55-70%
• Especially increased rates in mild/moderate abuse who might benefit most

• What about reduced risk?

If you cannot measure it, you cannot improve it.

• “If you can measure that of which you speak and express it in numbers,

• you know something about your subject;

• but if you cannot measure it,

• your knowledge is of a very meager and unsatisfactory kind.” (1883)

• William Thomson (Lord Kelvin) (1824-1907).

Research Team

• Kathy Bradley, MD

• Carol Achtmeyer, ARNP

• Anna DeBenedetti, BA

• Gwen Greiner, MPH

• Eric Hawkins, PhD

• Emily Williams, MPH

• Funding from

• CESATE

• VA HSR&D

• NIAAA R21AA14672

BAC & MI Web Resources

• Brief alcohol counseling

• 4 minute Boston University demo video (Case 3 at: http://www.bu.edu/act/mdalcoholtraining/cases.html

• NIAAA Clinicians Guide – updated 2007 http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm

• Motivational Interviewing

• 8 training videotapes: http://www.motivationalinterview.org/training/videos.html

• NIDA trainings including MI: http://mia.nattc.org/aboutUs/blendingInitiative/products2.htm#mi

References

• Biomarkers pf Alcohol Misuse

• Bean, P. Update on new biomarkers for detecting excessive alcohol use. AlcoholMD.com. November 2002. Available at: http://www.alcoholmd.com/pro/courses/biomarkers_of_alcohol_abuse.asp

• Wolff, K, Farrell, M, Marsden, J: A review of biological indicators of illicit drug use: Practical considerations and clinical usefulness. Addiction, 94:1279-98, 1999

• Screening Validity of AUDIT and AUDIT-C

• Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro M. AUDIT - The Alcohol Use Disorders Identification Test: Guidelines for use in primary health care. World Health Organization, 2001 http://www.who.int/substance_abuse/PDFfiles/auditbro.pdf

• Bradley, K.A., Bush, K., Epler, A., Dobie, D., Davis, T., Sporleder, J., Maynard, C., Burman, M. & Kivlahan, D. (2003). Two brief alcohol screening tests from the Alcohol Use Disorders Identification Test (AUDIT): Validation in a female VA patient population, Arch Int Med, 163, 821-829

• Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA: The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Arch Intern Med 158:1789-1795, 1998

• Association of AUDIT-C and Health Outcomes

• Au DH, et al. Alcohol Screening Scores and Risk of Hospitalizations for GI Conditions in Men. Alcoholism, clinical and experimental research 2007;31:443-451

• Bradley KA, et al. The relationship between alcohol screening questionnaires and mortality among male veteran outpatients. J Stud Alcohol 2001;62:826-833

• Bradley, KA, et al. (2004). "Using alcohol screening results and treatment history to assess the severity of at-risk drinking in VA primary care patients." Alcohol Clin Exp Res 28(3): 448-455.

• Reviews on BI/BAC

• Kaner E, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev 2007:CD004148 (Nice Cochrane review of brief alcohol counseling.)

• Maciosek MV, et al. Priorities among effective clinical preventive services results of a systematic review and analysis. Am J Prev Med 2006;31:52-61 (Established brief alcohol counseling one of top 10 US prevention priorities)

• NIAAA Clinicians Guide – updated 2007 (Includes DSM criteria for alcohol use disorders and review of medications for alcohol dependence.) http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm

• Whitlock EP, et al. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140:557-568 (Nice USPSTF review of evidence for brief alcohol counseling)

• Important RCT

• Fleming MF. Letters: Brief physician advice for problem alcohol drinkers. JAMA 1997;278:1059-1060. Economic analyses: Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcoholism, clinical and experimental research 2002;26:36-43

• Implementation and Performance Measurement

• Greenhalgh, T., et al., (2004). Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 82(4):581-629

• Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care 1998;7:149–58

• Miller WR, Sorensen JL, Selzer JA, Brigham GS. Disseminating evidence-based practices in substance abuse treatment: a review with suggestions. J. Subst Abuse Treat. 2006 31, 25-39.

• Pincus, H., et al. (2007). Can psychiatry cross the quality chasm? Improving the quality of health care for mental and substance use conditions. Am J Psychiatry,164(5):712-9.

• VA Quality Enhancement Research Initiative (QUERI) http://www.hsrd.research.va.gov/queri

• Tisnado DM, Adams JL, Liu H, Damberg CL, Chen WP, Hu FA, Carlisle DM, Mangione CM, Kahn KL.What is the concordance between the medical record and patient self-report as data sources for ambulatory care? Med Care. 2006 Feb;44(2):132-40.

Contact information

• Daniel Kivlahan, PhD

• Director, CESATE

• Clinical Coordinator, SUD QUERI

• VA Puget Sound Health Care System

• Phone: [phone]

• E-Mail: [e-mail]

Appendix

The Clients Perspective